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ERS/EAACI statement on adherence to international adult asthma guidelines

Alexander G. Mathioudakis, Olympia Tsilochristou, Ian M Adcock, Andras Bikov, Leif Bjermer, Enrico Clini, Breda Flood, Felix Herth, Ildiko Horvath, Omer Kalayci, Nikolaos G. Papadopoulos, Dermot Ryan, Silvia Sanchez Garcia, Jaime Correia-de-Sousa, Thomy Tonia, Hillary Pinnock, Ioana Agache, Christer Janson
European Respiratory Review 2021 30: 210132; DOI: 10.1183/16000617.0132-2021
Alexander G. Mathioudakis
1Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
2North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
21These authors were Task Force Co-chairs and are equal authors
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  • For correspondence: a.mathioudakis@nhs.net
Olympia Tsilochristou
3Dept of Allergy, Guy's and St Thomas’ Foundation Trust, London, UK
4Peter Gorer Dept of Immunobiology, King's College London, London, UK
21These authors were Task Force Co-chairs and are equal authors
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Ian M Adcock
5National Heart and Lung Institute, Imperial College London and the NIHR Imperial Biomedical Research Centre, London, UK
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Andras Bikov
1Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
2North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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Leif Bjermer
6Respiratory Medicine and Allergology, Dept of Clinical Sciences, Lund University, Lund, Sweden
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Enrico Clini
7Dept of Medical Specialities, University Hospital of Modena, University of Modena-Reggio Emilia, Modena, Italy
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Breda Flood
8European Federation of Allergy and Airways Diseases Patients Association (EFA), Dublin, Ireland
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Felix Herth
9Dept of Pneumology and Critical Care Medicine, Thoraxklinik and Translational Lung Research Center Heidelberg, University of Heidelberg, Heidelberg, Germany
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Ildiko Horvath
10National Koranyi Institute for Pulmonology, Budapest, Hungary
11Institute of Public Health, Semmelweis University, Budapest, Hungary
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Omer Kalayci
12Hacettepe University School of Medicine, Ankara, Turkey
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Nikolaos G. Papadopoulos
1Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, University of Manchester, Manchester, UK
13Allergy Dept, Paediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
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Dermot Ryan
14Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, UK
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Silvia Sanchez Garcia
15Allergy Dept, University Children's Hospital Niño Jesus, Madrid, Spain
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Jaime Correia-de-Sousa
16Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
17ICVS/3B's – PT Government Associate Laboratory, Guimarães, Portugal
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Thomy Tonia
18Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
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Hillary Pinnock
14Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh, UK
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Ioana Agache
19Allergy & Clinical Immunology, Transylvania University, Brasov, Romania
21These authors were Task Force Co-chairs and are equal authors
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Christer Janson
20Dept of Medical Science, Respiratory, Allergy and Sleep Research, Uppsala University and University Hospital, Uppsala, Sweden
21These authors were Task Force Co-chairs and are equal authors
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Figures

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  • FIGURE 1
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    FIGURE 1

    PRISMA flow diagram.

  • FIGURE 2
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    FIGURE 2

    Harvest plot summarising the findings of studies evaluating interventions to improve guidelines adherence for asthma assessment and maintenance management.

  • FIGURE 3
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    FIGURE 3

    Harvest plot summarising the findings of studies evaluating interventions to improve guidelines adherence for acute asthma attacks assessment and management.

  • FIGURE 4
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    FIGURE 4

    Harvest plot summarising the findings of studies evaluating differences in the adherence to asthma guidelines by specialists or generalists.

Tables

  • Figures
  • TABLE 1

    Systematic review (SR) questions

    SR-1: Effectiveness of strategies aimed to improve adherence to guidelines on the diagnosis, assessment and long-term management of asthma
    PopulationPatients with a clinical diagnosis of asthma. Patients with a clinical suspicion of asthma, for studies evaluating asthma diagnosis.
    InterventionInterventions aimed to improve the adherence of clinicians to guidelines on the diagnosis, assessment and long-term management of asthma.
    ComparatorAny other intervention aimed to improve the adherence of clinicians to guidelines on the diagnosis, assessment and long-term management of asthma, or no intervention.
    OutcomesClinical outcomes such as frequency of acute attacks, episodes of hospitalisation, asthma symptoms, or quality of life. Process outcomes, such as adherence to specific guidelines components (e.g. prescription of inhaled corticosteroids for patients requiring maintenance treatment, or delivery of smoking cessation advice).
    Types of studiesInterventional and observational comparative studies, including RCTs, cluster RCTs, comparative observational cohort studies or before-after studies.
    SR-2: Effectiveness of strategies aimed to improve adherence to guidelines on the diagnosis, assessment and management of acute attacks
    PopulationPatients with a clinical diagnosis of an acute asthma attack. Patients with a clinical suspicion of acute asthma attack, for studies evaluating asthma attack diagnosis.
    InterventionInterventions aimed to improve the adherence of clinicians to guidelines on the diagnosis, assessment and management of acute asthma.
    ComparatorAny other intervention aimed to improve the adherence of clinicians to guidelines on the diagnosis, assessment and management of acute asthma, or no intervention.
    OutcomesClinical outcomes such as need for hospital admission, duration of symptoms, treatment success or failure, need for intubation or mechanical ventilation. Process outcomes, such as adherence to specific guidelines components (e.g. prescription of oral corticosteroids for all patients with an acute attack leading to an emergency presentation or hospital admission).
    Types of studiesInterventional and observational comparative studies, including RCTs, cluster RCTs, comparative observational cohort studies or before-after studies.
    SR-3: Process and clinical outcomes in patients managed by specialists or generalists
    PopulationPatients with a clinical diagnosis of asthma or acute asthma attack. Patients with a clinical suspicion of asthma or acute asthma attack, for studies evaluating asthma or acute asthma attack diagnosis, respectively.
    Exposure AManagement by an asthma specialist (respiratory physician or allergist).
    Exposure BManagement by a generalist (general practitioner or internist, not specialised in asthma).
    OutcomesFor studies evaluating the diagnosis, assessment or long-term management of asthma: clinical outcomes such as frequency of acute attacks, episodes of hospitalisation, asthma symptoms, or quality of life. Process outcomes, such as adherence to specific guidelines components (e.g. prescription of inhaled corticosteroids for patients requiring maintenance treatment, or delivery of smoking cessation advice).
    For studies evaluating the diagnosis, assessment or management of acute asthma attacks: clinical outcomes such as need for hospital admission, duration of symptoms, treatment success or failure, need for intubation or mechanical ventilation. Process outcomes, such as adherence to specific guidelines components (e.g. prescription of oral corticosteroids for all patients with an acute attack leading to an emergency presentation or hospital admission).
    Types of studiesInterventional and observational comparative studies, including RCTs, cluster RCTs, comparative observational cohort studies or before-after studies.

    RCT: randomised controlled trial.

    • TABLE 2

      Healthcare profession/level of training and subsequent categorisation in the analyses of the survey

      Categoryn (%)Categories in the analyses
      1st survey: mild type 2 and severe type 2 asthma
       Allergy–asthma specialist22 (2.5)Allergy doctor
       Allergy specialist133 (15.2)Allergy doctor
       Trainee in allergy9 (1.0)Allergy doctor
       Respiratory–asthma specialist123 (14.1)Respiratory doctor
       Respiratory doctors456 (52.1)Respiratory doctor
       Trainee in respiratory medicine34 (3.9)Respiratory doctor
       General practitioner48 (5.5)Generalist
       Internist28 (3.2)Generalist
       Specialist nurse13 (1.5)Generalist
       Trainee general practitioner4 (0.5)Generalist
       Trainee in internal medicine4 (0.5)Generalist
       Nurse trainee1 (0.1)Generalist
      2nd survey: non-type 2 asthma
       Allergy–asthma specialist30 (4.4)Allergy doctor
       Allergy specialist163 (24.0)Allergy doctor
       Trainee in allergy12 (1.8)Allergy doctor
       Respiratory–asthma specialist80 (11.8)Respiratory doctor
       Respiratory doctors245 (36.1)Respiratory doctor
       Trainee in respiratory medicine13 (1.9)Respiratory doctor
       General practitioner99 (14.6)Generalist
       Internist16 (2.4)Generalist
       Specialist nurse14 (2.1)Generalist
       Trainee general practitioner4 (0.6)Generalist
       Trainee in internal medicine2 (0.3)Generalist
       Nurse trainee1 (0.2)Generalist
    • TABLE 3

      Preferred diagnostic procedure in different subtypes of asthma as reported in the online survey

      Allergy doctors (%)Respiratory doctors (%)Generalists (%)p-value#
      Mild type 2 asthma
       Spirometry with reversibility test95.096.486.90.001
       Peak flow24.127.839.30.04
       FeNO49.058.741.7<0.0001
       Blood eosinophils57.273.763.1<0.0001
       Total IgE49.763.641.70.006
       Skin prick test93.165.450.0<0.0001
       Specific IgE53.138.032.10.001
       Chest radiograph36.655.723.8<0.0001
       ENT examination31.731.429.80.95
       Bronchoscopy02.51.20.12
       Bronchial provocation19.331.920.20.002
       Bacterial culture4.17.47.10.38
       Detailed history70.368.166.70.82
       Chest auscultation55.948.341.70.10
       Serial peak flow53.162.975.00.004
      Severe type 2 asthma
       Spirometry with reversibility test98.096.485.10.001
       Peak flow19.224.125.50.55
       FeNO74.879.948.90.004
       Blood eosinophils79.885.968.10.006
       Total IgE60.677.636.2<0.0001
       Skin prick test99.078.457.4<0.0001
       Specific IgE55.641.034.00.01
       Chest radiograph39.459.827.7<0.0001
       ENT examination40.434.627.70.30
       Bronchoscopy1.01.72.10.86
       Bronchial provocation8.010.84.30.30
       Bacterial culture9.18.68.50.99
       Detailed history78.879.580.80.96
       Chest auscultation83.881.776.60.57
       Serial peak flow37.441.348.90.42
       Check prescriptions76.885.383.00.13
       Assess inhalation technique92.991.785.10.26
      Non-type 2 asthma
       Spirometry with reversibility test65.469.549.2<0.0001
       Peak flow14.621.028.40.009
       FeNO50.249.726.9<0.0001
       Blood eosinophils53.261.238.1<0.0001
       Total IgE44.947919.4<0.0001
       Skin prick test26.314.29.0<0.0001
       Specific IgE22.425.211.90.007
       Chest radiograph49.3055.930.6<0.0001
       ENT examination30.223.111.2<0.0001
       Bronchoscopy1.53.22.20.42
       Bronchial provocation1.54.12.20.17
       Bacterial culture17..117.84.50.001
       Detailed history65.867.853.70.01
       Chest auscultation68.871.261.20.12
       Occupational evaluation55.166.356.00.02
       Check adherence66.371.059.70.06
       Assess inhaler technique72.279.964.90.002

      FeNO: exhaled nitric oxide fraction; Ig: immunoglobulin; ENT: ear, nose and throat. #: refers to comparisons among the three groups, using the Chi-squared test.

      • TABLE 4

        Types of studies evaluating the adherence to asthma guidelines and the proportion of studies demonstrating beneficial clinical and adherence outcomes among the studies evaluating such outcomes

        Total NRCTs nBefore-after nComparative observational study nBeneficial clinical outcomesBeneficial process outcomes
        Assessment and management of asthma during stable disease state
         Additional patient specific input by a specialised health professional138238/12 (66.7)10/11 (90.9)
         Asthma care pathway4132/2 (100)3/3 (100)
         Computer decision-support systems7613/5 (60)4/7 (57.1)
         Introduction of a local or national guideline42110/1 (0)2/4 (50)
         Medical education12751/4 (25)5/10 (50)
         Quality improvement process113714/6 (66.7)8/10 (80)
         Participation in a clinical trial110/1 (0)0/1 (0)
        Assessment and management of acute asthma attacks
         Acute asthma care pathway121111/8 (12.5)10/12 (83.3)
         Additional patient specific input by a specialised health professional110/0 (N/A)1/1 (100)
         Computer decision-support systems110/0 (N/A)1/1 (100)
         Introduction of a local or national guideline110/0 (N/A)0/1 (0)
         Medical education110/0 (N/A)0/1 (0)
         Quality improvement process92522/3 (66.7)6/7 (85.7)

        Data are presented as n/N (%), unless otherwise stated. RCT: randomised controlled trial; N/A: not available.

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        ERS/EAACI statement on adherence to international adult asthma guidelines
        Alexander G. Mathioudakis, Olympia Tsilochristou, Ian M Adcock, Andras Bikov, Leif Bjermer, Enrico Clini, Breda Flood, Felix Herth, Ildiko Horvath, Omer Kalayci, Nikolaos G. Papadopoulos, Dermot Ryan, Silvia Sanchez Garcia, Jaime Correia-de-Sousa, Thomy Tonia, Hillary Pinnock, Ioana Agache, Christer Janson
        European Respiratory Review Sep 2021, 30 (161) 210132; DOI: 10.1183/16000617.0132-2021

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        ERS/EAACI statement on adherence to international adult asthma guidelines
        Alexander G. Mathioudakis, Olympia Tsilochristou, Ian M Adcock, Andras Bikov, Leif Bjermer, Enrico Clini, Breda Flood, Felix Herth, Ildiko Horvath, Omer Kalayci, Nikolaos G. Papadopoulos, Dermot Ryan, Silvia Sanchez Garcia, Jaime Correia-de-Sousa, Thomy Tonia, Hillary Pinnock, Ioana Agache, Christer Janson
        European Respiratory Review Sep 2021, 30 (161) 210132; DOI: 10.1183/16000617.0132-2021
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