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Ruissen MM, Steyerberg EW, Huisman SD, de Graaf AA, de Koning EJP, Delgado-Lista J, Sont JK. Critical comments regarding the assessment of quality of life and the clinical impact of the POWER2DM intervention. Reply to Pouwer F, Deschênes SS [letter]. Diabetologia 2024; 67:956-957. [PMID: 38427075 DOI: 10.1007/s00125-024-06119-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/11/2024] [Indexed: 03/02/2024]
Affiliation(s)
- Merel M Ruissen
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
- Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Sasja D Huisman
- Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert A de Graaf
- Netherlands Organization for Applied Scientific Research (TNO), Utrecht, the Netherlands
| | - Eelco J P de Koning
- Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Javier Delgado-Lista
- Lipids and Atherosclerosis Unit, Department of Internal Medicine, Reina Sofia University Hospital, Córdoba, Spain
| | - Jacob K Sont
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands.
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Ruissen MM, Torres-Peña JD, Uitbeijerse BS, Arenas de Larriva AP, Huisman SD, Namli T, Salzsieder E, Vogt L, Ploessnig M, van der Putte B, Merle A, Serra G, Rodríguez G, de Graaf AA, de Koning EJP, Delgado-Lista J, Sont JK. Clinical impact of an integrated e-health system for diabetes self-management support and shared decision making (POWER2DM): a randomised controlled trial. Diabetologia 2023; 66:2213-2225. [PMID: 37775611 PMCID: PMC10627940 DOI: 10.1007/s00125-023-06006-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 07/21/2023] [Indexed: 10/01/2023]
Abstract
AIMS/HYPOTHESIS There is a lack of e-health systems that integrate the complex variety of aspects relevant for diabetes self-management. We developed and field-tested an e-health system (POWER2DM) that integrates medical, psychological and behavioural aspects and connected wearables to support patients and healthcare professionals in shared decision making and diabetes self-management. METHODS Participants with type 1 or type 2 diabetes (aged >18 years) from hospital outpatient diabetes clinics in the Netherlands and Spain were randomised using randomisation software to POWER2DM or usual care for 37 weeks. This RCT assessed the change in HbA1c between the POWER2DM and usual care groups at the end of the study (37 weeks) as a primary outcome measure. Participants and clinicians were not blinded to the intervention. Changes in quality of life (QoL) (WHO-5 Well-Being Index [WHO-5]), diabetes self-management (Diabetes Self-Management Questionnaire - Revised [DSMQ-R]), glycaemic profiles from continuous glucose monitoring devices, awareness of hypoglycaemia (Clarke hypoglycaemia unawareness instrument), incidence of hypoglycaemic episodes and technology acceptance were secondary outcome measures. Additionally, sub-analyses were performed for participants with type 1 and type 2 diabetes separately. RESULTS A total of 226 participants participated in the trial (108 with type 1 diabetes; 118 with type 2 diabetes). In the POWER2DM group (n=111), HbA1c decreased from 60.6±14.7 mmol/mol (7.7±1.3%) to 56.7±12.1 mmol/mol (7.3±1.1%) (means ± SD, p<0.001), compared with no change in the usual care group (n=115) (baseline: 61.7±13.7 mmol/mol, 7.8±1.3%; end of study: 61.0±12.4 mmol/mol, 7.7±1.1%; p=0.19) (between-group difference 0.24%, p=0.008). In the sub-analyses in the POWER2DM group, HbA1c in participants with type 2 diabetes decreased from 62.3±17.3 mmol/mol (7.9±1.6%) to 54.3±11.1 mmol/mol (7.1±1.0%) (p<0.001) compared with no change in HbA1c in participants with type 1 diabetes (baseline: 58.8±11.2 mmol/mol [7.5±1.0%]; end of study: 59.2±12.7 mmol/mol [7.6±1.2%]; p=0.84). There was an increase in the time during which interstitial glucose levels were between 3.0 and 3.9 mmol/l in the POWER2DM group, but no increase in clinically relevant hypoglycaemia (interstitial glucose level below 3.0 mmol/l). QoL improved in participants with type 1 diabetes in the POWER2DM group compared with the usual care group (baseline: 15.7±3.8; end of study: 16.3±3.5; p=0.047 for between-group difference). Diabetes self-management improved in both participants with type 1 diabetes (from 7.3±1.2 to 7.7±1.2; p=0.002) and those with type 2 diabetes (from 6.5±1.3 to 6.7±1.3; p=0.003) within the POWER2DM group. The POWER2DM integrated e-health support was well accepted in daily life and no important adverse (or unexpected) effects or side effects were observed. CONCLUSIONS/INTERPRETATION POWER2DM improves HbA1c levels compared with usual care in those with type 2 diabetes, improves QoL in those with type 1 diabetes, improves diabetes self-management in those with type 1 and type 2 diabetes, and is well accepted in daily life. TRIAL REGISTRATION ClinicalTrials.gov NCT03588104. FUNDING This study was funded by the European Union's Horizon 2020 Research and Innovation Programme (grant agreement number 689444).
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Affiliation(s)
- Merel M Ruissen
- Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
- Department of Biomedical Data Sciences, Medical Decision Making Section, Leiden University Medical Center, Leiden, the Netherlands
| | - José D Torres-Peña
- Lipids and Atherosclerosis Unit, Department of Internal Medicine, Reina Sofía University Hospital, Córdoba, Spain
- Department of Medical and Surgical Sciences, University of Córdoba, Córdoba, Spain
- Maimonides Biomedical Research Institute of Córdoba, Córdoba, Spain
- Centro de Investigación Biomédica en Red Fisiopatologia de la Obesidad y Nutricion (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Bas S Uitbeijerse
- Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Antonio P Arenas de Larriva
- Lipids and Atherosclerosis Unit, Department of Internal Medicine, Reina Sofía University Hospital, Córdoba, Spain
- Department of Medical and Surgical Sciences, University of Córdoba, Córdoba, Spain
- Maimonides Biomedical Research Institute of Córdoba, Córdoba, Spain
- Centro de Investigación Biomédica en Red Fisiopatologia de la Obesidad y Nutricion (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Sasja D Huisman
- Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Tuncay Namli
- SRDC Software Research & Development and Consultancy Corp., Ankara, Turkey
| | | | - Lutz Vogt
- Diabetes Service Center GmbH, Karlsburg, Germany
| | | | | | | | | | | | - Albert A de Graaf
- Netherlands Organization for Applied Scientific Research (TNO), Utrecht, the Netherlands
| | - Eelco J P de Koning
- Department of Medicine, Leiden University Medical Center, Leiden, the Netherlands.
| | - Javier Delgado-Lista
- Lipids and Atherosclerosis Unit, Department of Internal Medicine, Reina Sofía University Hospital, Córdoba, Spain
- Department of Medical and Surgical Sciences, University of Córdoba, Córdoba, Spain
- Maimonides Biomedical Research Institute of Córdoba, Córdoba, Spain
- Centro de Investigación Biomédica en Red Fisiopatologia de la Obesidad y Nutricion (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Jacob K Sont
- Department of Biomedical Data Sciences, Medical Decision Making Section, Leiden University Medical Center, Leiden, the Netherlands
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Cardol CK, Meuleman Y, van Middendorp H, van der Boog PJ, Hilbrands LB, Navis G, Sijpkens YW, Sont JK, Evers AW, van Dijk S. Psychological Distress and Self-Management in CKD: A Cross-Sectional Study. Kidney Med 2023; 5:100712. [PMID: 37753249 PMCID: PMC10518713 DOI: 10.1016/j.xkme.2023.100712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
Rationale & Objective Patients with chronic kidney disease (CKD) not receiving dialysis, including kidney transplant recipients, often experience difficulties regarding self-management. An important barrier for adherence to self-management recommendations may be the presence of psychological distress, consisting of depressive and anxiety symptoms. We investigated relationships between psychological distress and adherence to self-management recommendations. Study Design Cross-sectional online questionnaire data as part of the E-GOAL study. Setting & Participants Patients with CKD (estimated glomerular filtration rate, 20-89 mL/min/1.73 m2) were recruited from April 2018 to October 2020 at 4 hospitals in The Netherlands and completed online screening questionnaires. Exposures Psychological distress, depressive symptoms, and anxiety symptoms. Outcomes Dietary adherence, physical activity, medication adherence, smoking, body mass index, and a CKD self-management index (ie, the sum of 5 binary indicators of nonadherence to the recommended self-management factors). Analytical Approach Adjusted multivariable regression and ordinal logistic regression analyses. Results In our sample (N = 460), 27.2% of patients reported psychological distress, and 69.8% were nonadherent to 1 or more recommendations. Higher psychological distress was significantly associated with poorer dietary adherence (βadj, -0.13; 95% CI, -0.23 to -0.04), less physical activity (βadj, -0.13; 95% CI, -0.22 to -0.03), and lower medication adherence (βadj, -0.15; 95% CI, -0.24 to -0.05), but not with smoking and body mass index. Findings were similar for depressive symptoms, whereas anxiety was only associated with poorer dietary and medication adherence. Every 1-point higher psychological distress was also associated with a higher likelihood of being nonadherent to an accumulating number of different recommendations (adjusted OR, 1.04; 95% CI, 1.02-1.07). Limitations Cross-sectional design, possible residual confounding, and self-report. Conclusions Many people with CKD experience psychological distress, of whom most have difficulties self-managing their CKD. Given the relationship between psychological distress and adherence to CKD self-management recommendations, behavioral interventions are needed to identify and treat psychological distress as a potential barrier to CKD self-management. Plain-Language Summary This online questionnaire study investigated relationships between psychological distress and self-management among 460 people with chronic kidney disease. Over a quarter of them reported mild-to-severe psychological distress. Alarmingly, 4 out of 5 patients with psychological distress were also nonadherent to 1 or more self-management recommendations, and higher levels of psychological distress were associated with poorer dietary and medication adherence and lower physical activity. Moreover, patients who suffered from moderate-to-severe distress were relatively more often nonadherent to 3 or more recommendations compared with patients with no or mild distress symptoms. So, it seems that psychological distress can be a barrier for self-management. To support patients in managing chronic kidney disease, researchers and health professionals should not overlook patients' mental health.
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Affiliation(s)
- Cinderella K. Cardol
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
| | - Yvette Meuleman
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Luuk B. Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerjan Navis
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
| | - Yvo W.J. Sijpkens
- Department of Internal Medicine, Haaglanden Medical Center Bronovo, The Hague, The Netherlands
| | - Jacob K. Sont
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrea W.M. Evers
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
- Medical Delta, Leiden University, TU Delft, and Erasmus University Rotterdam, The Netherlands
| | - Sandra van Dijk
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
- Medical Delta, Leiden University, TU Delft, and Erasmus University Rotterdam, The Netherlands
| | - E-GOAL Study Group
- Health, Medical and Neuropsychology Unit, Leiden University, Leiden, The Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Nephrology, University Medical Center Groningen, Groningen, The Netherlands
- Department of Internal Medicine, Haaglanden Medical Center Bronovo, The Hague, The Netherlands
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
- Medical Delta, Leiden University, TU Delft, and Erasmus University Rotterdam, The Netherlands
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van de Hei SJ, Kim CH, Honkoop PJ, Sont JK, Schermer TRJ, MacHale E, Costello RW, Kocks JWH, Postma MJ, van Boven JFM. Long-Term Cost-Effectiveness of Digital Inhaler Adherence Technologies in Difficult-to-Treat Asthma. J Allergy Clin Immunol Pract 2023; 11:3064-3073.e15. [PMID: 37406806 DOI: 10.1016/j.jaip.2023.06.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 06/14/2023] [Accepted: 06/19/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Digital inhalers can monitor inhaler usage, support difficult-to-treat asthma management, and inform step-up treatment decisions yet their economic value is unknown, hampering wide-scale implementation. OBJECTIVE We aimed to assess the long-term cost-effectiveness of digital inhaler-based medication adherence management in difficult-to-treat asthma. METHODS A model-based cost-utility analysis was performed. The Markov model structure was determined by biological and clinical understanding of asthma and was further informed by guideline-based assessment of model development. Internal and external validation was performed using the Assessment of the Validation Status of Health-Economic (AdViSHE) tool. The INCA (Inhaler Compliance Assessment) Sun randomized clinical trial data were incorporated into the model to evaluate the cost-effectiveness of digital inhalers. Several long-term clinical case scenarios were assessed (reduced number of exacerbations, increased asthma control, introduction of biosimilars [25% price-cut on biologics]). RESULTS The long-term modelled cost-effectiveness based on a societal perspective indicated 1-year per-patient costs for digital inhalers and usual care (ie, regular inhalers) of €7,546 ($7,946) and €10,752 ($11,322), respectively, reflecting cost savings of €3,207 ($3,377) for digital inhalers. Using a 10-year intervention duration and time horizon resulted in cost savings of €26,309 ($27,703) for digital inhalers. In the first year, add-on biologic therapies accounted for 69% of the total costs in the usual care group and for 49% in the digital inhaler group. Scenario analyses indicated consistent cost savings ranging from €2,287 ($2,408) (introduction biosimilars) to €4,581 ($4,824) (increased control, decreased exacerbations). CONCLUSIONS In patients with difficult-to-treat asthma, digital inhaler-based interventions can be cost-saving in the long-term by optimizing medication adherence and inhaler technique and reducing add-on biologic prescriptions.
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Affiliation(s)
- Susanne J van de Hei
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; General Practitioners Research Institute, Groningen, The Netherlands
| | - Chong H Kim
- Center for Pharmaceutical Outcomes Research, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado, Denver, Colo
| | - Persijn J Honkoop
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacob K Sont
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Tjard R J Schermer
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands; Science Support Office, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Elaine MacHale
- Clinical Research Centre, Smurfit Building Beaumont Hospital, Department of Respiratory Medicine, RCSI, Dublin, Ireland
| | - Richard W Costello
- Clinical Research Centre, Smurfit Building Beaumont Hospital, Department of Respiratory Medicine, RCSI, Dublin, Ireland
| | - Janwillem W H Kocks
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; General Practitioners Research Institute, Groningen, The Netherlands; Medication Adherence Expertise Center of the Northern Netherlands (MAECON), Groningen, The Netherlands; Observational and Pragmatic Research Institute, Singapore
| | - Maarten J Postma
- Department of Health Sciences, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Center of Excellence for Pharmaceutical Care Innovation, Padjadjaran University, Bandung, Indonesia; Department of Economics, Econometrics & Finance, University of Groningen, Faculty of Economics & Business, Groningen, The Netherlands
| | - Job F M van Boven
- Groningen Research Institute for Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Medication Adherence Expertise Center of the Northern Netherlands (MAECON), Groningen, The Netherlands; Department of Clinical Pharmacy & Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
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Ten Have L, Visser E, Meulmeester FL, Bendien SA, Braunstahl GJ, Broeders MEAC, Fieten KB, Hashimoto S, van Huisstede A, Langeveld B, Oud KTM, Patberg KW, Smeenk FWJM, van Veen A, van Veen IH, van de Ven MJT, Weersink EJM, de Jong K, Sont JK, Kroes JA, Ten Brinke A. Long-Term Weight Changes After Starting Anti-IL-5/5Ra Biologics in Severe Asthma: The Role of Oral Corticosteroids. J Allergy Clin Immunol Pract 2023; 11:2748-2756.e3. [PMID: 37399945 DOI: 10.1016/j.jaip.2023.06.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/16/2023] [Accepted: 06/23/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Many patients with severe asthma are overweight or obese, often attributed to unintentional weight gain as a side effect of oral corticosteroids (OCSs). Anti-IL-5/5Ra biologics significantly reduce OCS use, but their long-term effects on weight are unknown. OBJECTIVES To examine (1) weight change up to 2 years after anti-IL-5/5Ra initiation in subgroups on the basis of maintenance OCS use at start of treatment and (2) whether cumulative OCS exposure before or changes in OCS exposure during treatment are related to weight change. METHODS Real-world data on weight and cumulative OCS dose from adults included in the Dutch Registry of Adult Patients with Severe asthma for Optimal DIsease management before and at least 2 years after starting anti-IL-5/5Ra were analyzed using linear mixed models and linear regression analyses. RESULTS For the included 389 patients (55% female; mean body mass index, 28 ± 5 kg/m2; 58% maintenance OCS), mean weight decreased -0.27 kg/y (95% CI, -0.51 to -0.03; P = .03), with more weight loss in patients with maintenance OCS use than in those without maintenance OCS use (-0.87 kg/y [95% CI, -1.21 to -0.52; P < .001] vs +0.54 kg/y [0.26 to 0.82; P < .001]). Greater weight loss at 2 years was associated with higher cumulative OCS dose in the 2 years before anti-IL-5/5Ra initiation (β = -0.24 kg/g; 95% CI, -0.38 to -0.10; P < .001) and, independently, greater reduction in cumulative OCS dose during follow-up (β = 0.27 kg/g; 95% CI, 0.11 to 0.43; P < .001). CONCLUSIONS Anti-IL-5/5Ra therapy is associated with long-term weight reduction, especially in patients with higher OCS exposure before treatment and those able to reduce OCS use during treatment. However, the effect is small and does not apply to all patients, and so additional interventions seem necessary if weight change is desired.
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Affiliation(s)
- Lianne Ten Have
- Department of Epidemiology, Medical Center Leeuwarden, Leeuwarden, The Netherlands; Department of Biomedical Data Science, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands.
| | - Edith Visser
- Department of Epidemiology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Fleur L Meulmeester
- Department of Biomedical Data Science, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Sarah A Bendien
- Department of Respiratory Medicine, HAGA Teaching Hospital, Den Haag, The Netherlands
| | - Gert-Jan Braunstahl
- Department of Respiratory Medicine, St Franciscus Gasthuis en Vlietland, Rotterdam, The Netherlands
| | - Marielle E A C Broeders
- Department of Respiratory Medicine, Jeroen Bosch Hospital, 's Hertogenbosch, The Netherlands
| | - Karin B Fieten
- Nederlands Astmacentrum Davos, Davos, Switzerland; Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, Zurich, Switzerland
| | - Simone Hashimoto
- Department of Pulmonary Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Bas Langeveld
- Department of Respiratory Medicine, Deventer Ziekenhuis, Deventer, The Netherlands
| | - Karen T M Oud
- Department of Respiratory Medicine, Ziekenhuis Gelderse Vallei, Ede, The Netherlands
| | - Kornelis W Patberg
- Department of Respiratory Medicine, ISALA Clinics, Zwolle, The Netherlands
| | - Frank W J M Smeenk
- Department of Respiratory Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | - Anneke van Veen
- Department of Respiratory Medicine, Canisius Wilhelmina Ziekenhuis, Nijmegen, The Netherlands
| | - Ilonka H van Veen
- Department of Respiratory Medicine, Medisch Spectrum Twente, Enschede, The Netherlands
| | | | - Els J M Weersink
- Department of Pulmonary Medicine, Amsterdam UMC, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Kim de Jong
- Department of Epidemiology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Jacob K Sont
- Department of Biomedical Data Science, Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Johannes A Kroes
- Department of Clinical Pharmacy and Pharmacology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Anneke Ten Brinke
- Department of Pulmonary Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherlands
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Principe S, Richards LB, Hashimoto S, Kroes JA, Van Bragt JJMH, Vijverberg SJ, Sont JK, Scichilone N, Bieksiene K, Ten Brinke A, Csoma Z, Dahlén B, Gemicioglu B, Grisle I, Kuna P, Lazic Z, Mihaltan F, Popović-Grle S, Škrgat S, Marcon A, Caminati M, Djukanovic R, Porsbjerg C, Maitland Van Der Zee AH. Characteristics of severe asthma patients on biologics; a real-life European registry study. ERJ Open Res 2023; 9:00586-2022. [PMID: 37143845 PMCID: PMC10152256 DOI: 10.1183/23120541.00586-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/21/2023] [Indexed: 04/09/2023] Open
Abstract
BackgroundThe use of anti-IL5 for severe asthma is based on criteria from randomized controlled trials(RCTs) but in real-life patient might not fulfil eligibility criteria but benefit from biologics. We aimed to: characterise patients starting in anti-IL5(R) in Europe and evaluate the discrepancies between initiation of anti-IL5(R) in real-life and in RCTs.Material and methodsWe performed a cross-sectional analysis with data from the severe asthma patients at the start of anti-IL5(R) in the Severe Heterogeneous Asthma Research collaboration Patient-centered(SHARP-Central)registry. We compared the baseline characteristics of the anti-IL5(R) from 11 European countries within SHARP with the baseline characteristics of the severe asthma patients from 10 RCTs (4 for mepolizumab, 3 for benralizumab and 3 for reslizumab). Patients were evaluated following eligibility criteria from the RCTs of anti-IL5 therapies.ResultsPatients anti-IL5(R) starters in Europe (n=1231) differed in terms of smoking history, clinical characteristics and medication use. The characteristics of severe asthma patients in SHARP Registry differed from the characteristics of patients in RCTs. Only 327(26,56%) fulfilled eligibility criteria of all the RCTs; 24 patients were eligible for mepolizumab,100 for benralizumab and 52 reslizumab. The main characteristics of ineligibility were: pack/years≥10, respiratory diseases other than asthma, ACQ score≤1.5, low dose ICS.ConclusionA large proportion of patients in the SHARP registry would not have been eligible for anti-IL-5(R) treatment RCTs, demonstrating the importance of real life cohorts in describing the efficacy of biologics in a broader population of patients with severe asthma.
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van der Valk JPM, Hekking PP, Rauh SP, Patberg KW, van Veen HPAA, Van Huisstede A, Smeenk FWJM, van de Ven MJT, Broeders MEAC, Hilvering B, van Exsel J, Oud KTM, Langeveld B, Fieten KB, van Veen A, Hashimoto S, Sont JK, Brinke AT, Braunstahl GJ. Anti-IL-5/5Ra biologics improve work productivity and activity in severe asthma: A RAPSODI registry-based cohort study. J Asthma 2023:1-8. [PMID: 36976568 DOI: 10.1080/02770903.2023.2196563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Severe asthma is associated with a serious disease burden, partially caused by limitations in activity and work impairment (1,2). AIMS AND OBJECTIVES This study aims to relate treatment with biologics targeting IL-5/5Ra to work productivity and activity in the long term in a real-world context. MATERIAL AND METHODS This is a registry-based multi-center cohort study evaluating data from adults with severe eosinophilic asthma included in the Dutch Register of Adult Patients with Severe Asthma for Optimal DIsease management (RAPSODI). Patients that started with anti-IL-5/5Ra biologics and completed the work productivity and activity improvement questionnaire, were included. Study and patient characteristics were compared between the employed and unemployed patients. Work productivity and activity impairment are related to accompanying improvements in clinical outcomes. RESULTS At baseline, 91 of 137 patients (66%) were employed which remained stable throughout the follow-up period. Patients in the working age category were younger and had significantly better asthma control (p =0.02). Mean overall work impairment due to health decreased significantly from 25.5% (SD2.6) to 17.6% (SD 2.8) during 12 months anti-IL-5/5Ra biologics treatment (P = 0.010). There was a significant association between ACQ6 and overall work improvement after targeted therapy (β =8.7, CI 2.1-15.4, P = 0.01). The improvement of asthma control of 0.5 points on the asthma Control Questionnaire was associated with an overall work impairment of - 9%. CONCLUSIONS Work productivity and activity in severe eosinophilic asthma improved after starting anti-IL-5/5Ra biologics. Clinically relevant improvement in asthma control was associated with an overall work impairment score of - 9% in this study.
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Affiliation(s)
- J P M van der Valk
- Department of Pulmonary Medicine, STZ Center of Excellence for Asthma and COPD, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - P P Hekking
- Department of Pulmonary Medicine, STZ Center of Excellence for Asthma and COPD, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - S P Rauh
- Department of science, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - K W Patberg
- Department of Pulmonary Medicine, Isala, Zwolle, The Netherlands
| | - H P A A van Veen
- Department of Pulmonary Medicine, Medical Center Twente, The Netherlands
| | - A Van Huisstede
- Department of Pulmonary Medicine, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - F W J M Smeenk
- Department of Pulmonary Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | - M J T van de Ven
- Department of Pulmonary Medicine, Rijnstate, Arnhem, The Netherlands
| | - M E A C Broeders
- Department of Pulmonary Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - B Hilvering
- Department of Pulmonary Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - J van Exsel
- Department of Pulmonary Medicine, Haga Hospital, The Hague, The Netherlands
| | - K T M Oud
- Department of Pulmonary Medicine, Hospital Gelderse Vallei, Ede, The Netherlands
| | - B Langeveld
- Department of Pulmonary Medicine, Deventer Hospital, Deventer, The Netherlands
| | - K B Fieten
- Dutch Asthma Center Davos, Davos, Switzerland
| | - A van Veen
- Department of Pulmonary Medicine, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - S Hashimoto
- Department of Pulmonary Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - J K Sont
- Department of Biomedical Data Science, Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - A Ten Brinke
- Department of Pulmonary Medicine, Medical Center Leeuwarden, Leeuwarden, The Netherland
| | - G J Braunstahl
- Department of Pulmonary Medicine, STZ Center of Excellence for Asthma and COPD, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
- Department of Pulmonary Medicine, Erasmus MC, Rotterdam, The Netherlands
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8
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Kroes JA, Alfonso-Cristancho R, Bansal AT, Berret E, Bieksiene K, Bourdin A, Brussino L, Canhoto D, Cardini C, Celik G, Csoma Z, Dahlén B, Damadoglu E, Eger K, Gauquelin L, Gemicioglu B, Goksel O, Graff S, Heffler E, Hofstee HB, Howarth P, Jakes RW, Jaun F, Kalinauskaite-Zukauske V, Kopač P, Kwon N, Loureiro CC, Lozoya García V, Masoli M, Paula Rezelj M, De Llano LP, Popović-Grle S, Ramos-Barbon D, Sà Sousa A, Samitas K, Schleich F, Sirena C, Skrgat S, Zervas E, Zichnalis G, Bel EH, Sont JK, Hashimoto S, Ten Brinke A. Evaluation of Real-World Mepolizumab Use in Severe Asthma across Europe - the SHARP experience with privacy-preserving federated analysis. ERJ Open Res 2023; 9:00745-2022. [PMID: 37020841 PMCID: PMC10068512 DOI: 10.1183/23120541.00745-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 01/03/2023] [Indexed: 03/11/2023] Open
Abstract
BackgroundAn objective of the Severe Heterogeneous Asthma Registry, Patient-centered (SHARP) is to produce real-world evidence on a pan-European scale by linking non-standardized, patient-level registry-data. Mepolizumab has shown clinical efficacy in RCTs and prospective real-world studies and could therefore serve as a proof of principle for this novel approach.AimTo harmonize data from 10 national severe asthma registries and characterize patients receiving mepolizumab, assess its effectiveness on annual exacerbations and maintenance oral glucocorticoid (OCS) use, and evaluate treatment patterns.MethodsIn this observational cohort study, registry data (5871 patients) were extracted for harmonization. Where harmonization was possible, patients who initiated mepolizumab between 1-1-2016 and 31-12-2021 were examined. Changes of a 12 (range 11–18) months period in frequent (≥2) exacerbations, maintenance OCS use and dose were analyzed in a privacy-preserving manner using meta-analysis of generalized estimating equation parameters. Periods before and during the COVID-19 pandemic were analyzed separately.ResultsIn 912 patients who fulfilled selection criteria mepolizumab significantly reduced frequent exacerbations (OR;95%CI: 0.18;0.13–0.25), maintenance OCS use (OR;95%CI: 0.75;0.61–0.92) and dose (mean; 95%CI: −3.93 mg·day−1; −5.24–2.62) in the Pre-Pandemic group, with similar trends in the Pandemic group. Marked heterogeneity was observed between registries in patient characteristics and mepolizumab treatment patterns.ConclusionsBy harmonizing patient-level registry data and applying federated analysis, SHARP demonstrated the real-wold effectiveness of mepolizumab on asthma exacerbations and maintenance OCS use in severe asthma patients across Europe, consistent with previous evidence. This paves the way for future pan-European real-world severe asthma studies using patient-level data in a privacy-proof manner.
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9
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Kroes JA, de Jong K, Hashimoto S, Zielhuis SW, van Roon EN, Sont JK, ten Brinke A. Clinical response to benralizumab can be predicted by combining clinical outcomes at 3 months with baseline characteristics. ERJ Open Res 2023; 9:00559-2022. [PMID: 37057095 PMCID: PMC10086738 DOI: 10.1183/23120541.00559-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 01/15/2023] [Indexed: 01/27/2023] Open
Abstract
BackgroundBenralizumab is highly effective in many, but not all, patients with severe asthma. Baseline characteristics alone are insufficient to predict an individual's probability of long-term benralizumab response.ObjectivesTo (1) study whether parameters at 3 months –in addition to baseline characteristics– contribute to the prediction of benralizumab response at 1 year and to (2) develop an easy-to-use prediction tool to assess an individual's probability of long-term response.MethodsWe assessed the effect of benralizumab treatment in 192 patients from the Dutch severe asthma registry (RAPSODI). To investigate predictors of long-term benralizumab response (≥50% reduction in maintenance oral corticosteroid (OCS) dose or annual exacerbation frequency) we used logistic regression, including baseline characteristics and 3-month Asthma Control Questionnaire (ACQ-6) score and maintenance OCS dose.ResultsBenralizumab treatment significantly improved several clinical outcomes and 144 (75%) patients were classified as long-term responders. Response prediction improved significantly when 3-month outcomes were added to a predictive model with baseline characteristics only (AUROC 0.85versus0.72, p=0.001). Based on this model, a prediction tool using gender, prior biologic use, baseline blood eosinophils, FEV1and at 3 months OCS dose and ACQ-6 was developed which classified patients into 3 categories with increasing probability of long-term response (95%CI): 25%(3–65), 67%(57–77) and 97%(91–99) respectively.ConclusionIn addition to baseline characteristics, treatment outcomes at 3 months contribute to the prediction of benralizumab response at 1 year in patients with severe eosinophilic asthma. Prediction tools as proposed in this study may help physicians optimize the use of costly biologics.
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10
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de Hond AAH, Kant IMJ, Honkoop PJ, Smith AD, Steyerberg EW, Sont JK. Machine learning did not beat logistic regression in time series prediction for severe asthma exacerbations. Sci Rep 2022; 12:20363. [PMID: 36437306 PMCID: PMC9701686 DOI: 10.1038/s41598-022-24909-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 11/22/2022] [Indexed: 11/28/2022] Open
Abstract
Early detection of severe asthma exacerbations through home monitoring data in patients with stable mild-to-moderate chronic asthma could help to timely adjust medication. We evaluated the potential of machine learning methods compared to a clinical rule and logistic regression to predict severe exacerbations. We used daily home monitoring data from two studies in asthma patients (development: n = 165 and validation: n = 101 patients). Two ML models (XGBoost, one class SVM) and a logistic regression model provided predictions based on peak expiratory flow and asthma symptoms. These models were compared with an asthma action plan rule. Severe exacerbations occurred in 0.2% of all daily measurements in the development (154/92,787 days) and validation cohorts (94/40,185 days). The AUC of the best performing XGBoost was 0.85 (0.82-0.87) and 0.88 (0.86-0.90) for logistic regression in the validation cohort. The XGBoost model provided overly extreme risk estimates, whereas the logistic regression underestimated predicted risks. Sensitivity and specificity were better overall for XGBoost and logistic regression compared to one class SVM and the clinical rule. We conclude that ML models did not beat logistic regression in predicting short-term severe asthma exacerbations based on home monitoring data. Clinical application remains challenging in settings with low event incidence and high false alarm rates with high sensitivity.
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Affiliation(s)
- Anne A. H. de Hond
- grid.10419.3d0000000089452978Department of Information Technology and Digital Innovation, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, The Netherlands ,grid.10419.3d0000000089452978Clinical AI Implementation and Research Lab, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, The Netherlands ,grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands
| | - Ilse M. J. Kant
- grid.10419.3d0000000089452978Department of Information Technology and Digital Innovation, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, The Netherlands ,grid.10419.3d0000000089452978Clinical AI Implementation and Research Lab, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, The Netherlands ,grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands
| | - Persijn J. Honkoop
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands
| | - Andrew D. Smith
- grid.417145.20000 0004 0624 9990Department of Respiratory Medicine, University Hospital Wishaw, 50 Netherton Street, Wishaw, ML2 0DP UK
| | - Ewout W. Steyerberg
- grid.10419.3d0000000089452978Clinical AI Implementation and Research Lab, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, The Netherlands ,grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands
| | - Jacob K. Sont
- grid.10419.3d0000000089452978Department of Biomedical Data Sciences, Leiden University Medical Centre, Albinusdreef 2, 2300 RC Leiden, the Netherlands
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Perez-Corral I, Gomez-Delgado F, Ruissen MM, Torres-Peña JD, Larriva APAD, Sont JK, de Graaf AA, Uitbeijerse BS, de Koning EJP, Delgado-Lista J. Sleep duration and lipid metabolism in patients with diabetes mellitus: from the POWER2DM study. Sleep Biol Rhythms 2022; 20:595-599. [PMID: 38468620 PMCID: PMC10899896 DOI: 10.1007/s41105-022-00403-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/04/2022] [Indexed: 10/16/2022]
Abstract
This study assesses the association between sleep duration and plasma lipid profiles in people with diabetes mellitus (DM). Sleep duration data were obtained in 91 patients from the POWER2DM study (NCT03588104). The patients were divided in tertiles, based on their sleep duration, and blood samples were obtained at the beginning and after 9 months. Significant differences were found, specifically, patients in Tertile 3 (≥ 7.51 h) showed lower plasma levels of high-density lipoprotein cholesterol HDL-c (p < 0.05), apolipoprotein A1 (apo-A1; p < 0.05) and low HDL-c/apo-A1 ratio (p < 0.05). This study shows that sleep duration is associated with plasma lipid profiles in people with DM.
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Affiliation(s)
- Isabel Perez-Corral
- Lipids and Atherosclerosis Unit, Internal Medicine Unit, Reina Sofia University Hospital, Avda. Menendez Pidal, S/N., 14004 Cordoba, Spain
- Department of Medical and Surgical Sciences, University of Cordoba, 14004 Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- CIBER Fisiopatologia de La Obesidad Y Nutricion (CIBEROBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Francisco Gomez-Delgado
- Lipids and Atherosclerosis Unit, Internal Medicine Unit, Reina Sofia University Hospital, Avda. Menendez Pidal, S/N., 14004 Cordoba, Spain
- Department of Medical and Surgical Sciences, University of Cordoba, 14004 Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- CIBER Fisiopatologia de La Obesidad Y Nutricion (CIBEROBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Merel M. Ruissen
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Zuid-Holland The Netherlands
| | - Jose D. Torres-Peña
- Lipids and Atherosclerosis Unit, Internal Medicine Unit, Reina Sofia University Hospital, Avda. Menendez Pidal, S/N., 14004 Cordoba, Spain
- Department of Medical and Surgical Sciences, University of Cordoba, 14004 Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- CIBER Fisiopatologia de La Obesidad Y Nutricion (CIBEROBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Antonio P. Arenas-de Larriva
- Lipids and Atherosclerosis Unit, Internal Medicine Unit, Reina Sofia University Hospital, Avda. Menendez Pidal, S/N., 14004 Cordoba, Spain
- Department of Medical and Surgical Sciences, University of Cordoba, 14004 Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- CIBER Fisiopatologia de La Obesidad Y Nutricion (CIBEROBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Jacob K. Sont
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Albert A. de Graaf
- Department Risk Analysis for Products in Development, The Netherlands Organization for Applied Scientific Research (TNO), 3508 TA Utrecht, The Netherlands
| | - Bas S. Uitbeijerse
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Zuid-Holland The Netherlands
| | - Eelco J. P. de Koning
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Leiden, Zuid-Holland The Netherlands
| | - Javier Delgado-Lista
- Lipids and Atherosclerosis Unit, Internal Medicine Unit, Reina Sofia University Hospital, Avda. Menendez Pidal, S/N., 14004 Cordoba, Spain
- Department of Medical and Surgical Sciences, University of Cordoba, 14004 Cordoba, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Cordoba, Spain
- CIBER Fisiopatologia de La Obesidad Y Nutricion (CIBEROBN), Instituto de Salud Carlos III, 28029 Madrid, Spain
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12
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Hashimoto S, Kroes JA, Eger KA, Mau Asam PF, Hofstee HB, Bendien SA, Braunstahl GJ, Broeders MEAC, Imming LM, Langeveld B, Maitland-van der Zee AH, Oud KTM, Patberg KW, Smeenk FWJM, Romme EAPM, van Bezouw MJ, van de Ven MJ, van Veen A, van Velzen E, van Veen IHPAA, Weersink EJM, Ten Brinke A, Sont JK, Bel EH. Real-World Effectiveness of Reslizumab in Patients With Severe Eosinophilic Asthma - First Initiators and Switchers. J Allergy Clin Immunol Pract 2022; 10:2099-2108.e6. [PMID: 35487369 DOI: 10.1016/j.jaip.2022.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 04/04/2022] [Accepted: 04/05/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Reslizumab, a biologic targeting IL-5, has been shown to reduce asthma exacerbations and maintenance oral corticosteroid use in randomized controlled trials and pre-post studies in patients with severe eosinophilic asthma. However, real-world effectiveness data of reslizumab are scarce, and it is unknown whether reslizumab has added value after switching from another type 2 biologic. OBJECTIVE To evaluate (1) the real-world effectiveness of reslizumab on severe asthma exacerbations, maintenance oral corticosteroid use, and overall treatment response, both in biologic-naive patients who initiated reslizumab and in those who switched from another type 2 biologic; and (2) physicians' experience with reslizumab treatment. METHODS This observational real-world study evaluated data from 134 adults with severe eosinophilic asthma included in the Dutch severe asthma registry (RAPSODI), who initiated reslizumab treatment (4-weekly infusions, 0.3 mg/kg) before April 2020 and had follow-up data for 6 months and greater. Clinical asthma experts completed surveys on their experience with reslizumab treatment. RESULTS Overall, reslizumab reduced the exacerbation rate (odds ratio [95% CI] = 0.10 [0.05-0.21]; P < .001), oral corticosteroid use (OR [95% CI], 0.2 [0.0-0.5]; P < .001), and maintenance dose (median [CI], 5.0 [0.0-10.0] to 0.0 [0.0-5.0]; P < .001), with comparable results in biologic-naive reslizumab initiators and switchers. The overall response to reslizumab was graded good or excellent in 59.2% of patients. The additive effectiveness of reslizumab after switching from another biologic was reflected in physicians' surveys. CONCLUSIONS Real-world data show that reslizumab reduces severe asthma exacerbations and oral corticosteroid use in patients with severe eosinophilic asthma, both in biologic-naive reslizumab initiators and in those who switched from another type 2 biologic. This additional value of reslizumab was recognized by clinical asthma experts.
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Affiliation(s)
- Simone Hashimoto
- Department of Pulmonary Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Johannes A Kroes
- Department of Clinical Pharmacy and Pharmacology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Katrien A Eger
- Department of Pulmonary Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pearl F Mau Asam
- Department of Pulmonary Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hendrik B Hofstee
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Sarah A Bendien
- Department of Respiratory Medicine, Haga Teaching Hospital, The Hague, The Netherlands
| | | | | | - Leonie M Imming
- Department of Pulmonology, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Bas Langeveld
- Department of Pulmonology, Deventer Ziekenhuis, Schalkhaar, The Netherlands
| | | | | | | | - Frank W J M Smeenk
- Department of Pulmonology, Catharina Hospital, Eindhoven, The Netherlands; Department of Educational Development and Research, School of Health Professions Education, Maastricht University, Maastricht, The Netherlands
| | | | - Maarten J van Bezouw
- Department of Work and Organizational Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Anneke van Veen
- Canisius Wilhelmina Ziekenhuis Nijmegen, Nijmegen, The Netherlands
| | - Edwin van Velzen
- Department of Respiratory Medicine, Meander Medical Center, Amersfoort, The Netherlands
| | | | - Els J M Weersink
- Department of Pulmonary Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Anneke Ten Brinke
- Department of Pulmonology, Leeuwarden Medical Center, Leeuwarden, the Netherlands
| | - Jacob K Sont
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Elisabeth H Bel
- Department of Pulmonary Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands; Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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13
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Kroes JA, Bansal AT, Berret E, Christian N, Kremer A, Alloni A, Gabetta M, Marshall C, Wagers S, Djukanovic R, Porsbjerg C, Hamerlijnck D, Fulton O, ten Brinke A, Bel EH, Sont JK. Blueprint for harmonizing non-standardized disease registries to allow federated data analysis – prepare for the future. ERJ Open Res 2022; 8:00168-2022. [PMID: 36199590 PMCID: PMC9530887 DOI: 10.1183/23120541.00168-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/29/2022] [Indexed: 11/30/2022] Open
Abstract
Real-world evidence from multinational disease registries is becoming increasingly important not only for confirming the results of randomised controlled trials, but also for identifying phenotypes, monitoring disease progression, predicting response to new drugs and early detection of rare side-effects. With new open-access technologies, it has become feasible to harmonise patient data from different disease registries and use it for data analysis without compromising privacy rules. Here, we provide a blueprint for how a clinical research collaboration can successfully use real-world data from existing disease registries to perform federated analyses. We describe how the European severe asthma clinical research collaboration SHARP (Severe Heterogeneous Asthma Research collaboration, Patient-centred) fulfilled the harmonisation process from nonstandardised clinical registry data to the Observational Medical Outcomes Partnership Common Data Model and built a strong network of collaborators from multiple disciplines and countries. The blueprint covers organisational, financial, conceptual, technical, analytical and research aspects, and discusses both the challenges and the lessons learned. All in all, setting up a federated data network is a complex process that requires thorough preparation, but above all, it is a worthwhile investment for all clinical research collaborations, especially in view of the emerging applications of artificial intelligence and federated learning. Harmonising real-world patient data from diverse registries to allow federated analyses is a complex process that requires thorough preparation but is above all a valuable investment, especially in view of emerging applications of artificial intelligencehttps://bit.ly/3NEKKnV
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Kroes JA, Zielhuis SW, De Jong K, Hashimoto S, Sont JK, Zielhuis SW, Van Roon EN, Bel EH, Ten Brinke A. Cumulative Corticosteroid Sparing Effect of Anti-Interleukin-5/5Ra In Eosinophilic Asthma. Eur Respir J 2022; 60:13993003.02983-2021. [PMID: 35595317 PMCID: PMC9630606 DOI: 10.1183/13993003.02983-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 03/31/2022] [Indexed: 11/20/2022]
Abstract
Background Anti-interleukin (IL)-5/IL-5 receptor α (IL-5Ra) therapy has been shown to reduce maintenance oral corticosteroid (OCS) dose in severe eosinophilic asthma. However, the effect on cumulative OCS exposure is currently unknown. Neither is it known how prior OCS exposure affects response to anti-IL-5/5Ra treatment. We aimed primarily to compare the cumulative OCS exposure over a 2-year period before and after anti-IL-5/5Ra initiation, and secondarily to investigate whether duration and cumulative OCS exposure prior to anti-IL-5/5Ra influence the ability to discontinue OCS within 2 years of anti-IL-5/5Ra therapy. Methods This real-world nationwide observational registry-based study evaluated all dispensed OCS from 389 adults with severe eosinophilic asthma included in the Dutch Severe Asthma Registry (RAPSODI) 2 years before and 2 years after initiating anti-IL-5/5Ra. The Wilcoxon signed-rank test and multivariable regression analyses were used. Results Median (interquartile range) cumulative OCS exposure in the 2 years before and after anti-IL-5/5Ra initiation decreased from 2.715 (1.150–5.539) to 1.050 (0.300–3.640) g (p<0.001). 52% of patients were able to discontinue OCS within 2 years after anti-IL-5/5Ra therapy, which was independently predicted by lower and shorter prior OCS exposure. Conclusions This real-world study showed that anti-IL-5/5Ra therapy leads to a significant reduction in cumulative OCS exposure over a 2-year period. Patients with lower and shorter OCS exposure were more likely to completely eliminate OCS. Since cumulative exposure increased progressively prior to anti-IL-5/5Ra initiation, our data suggest that early intervention leads to a better long-term prognosis in patients with severe eosinophilic asthma. Anti-IL-5/5Ra therapy leads to a reduction in cumulative oral corticosteroid exposure over a 2-year period. This study suggests that early anti-IL-5/5Ra intervention leads to a better long-term prognosis in patients with severe eosinophilic asthma.https://bit.ly/3jzVGqw
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Affiliation(s)
- Johannes A Kroes
- Department of Clinical Pharmacy and Pharmacology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands .,Unit of Pharmacotherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Sybrand Wj Zielhuis
- Unit of Pharmacotherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Kim De Jong
- Department of Epidemiology, Medical Centre Leeuwarden Academy, Leeuwarden, The Netherlands
| | - Simone Hashimoto
- Department of Respiratory Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Jacob K Sont
- Department of Biomedical Data Sciences, section Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - Sander W Zielhuis
- Department of Clinical Pharmacy and Pharmacology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Eric N Van Roon
- Department of Clinical Pharmacy and Pharmacology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands.,Unit of Pharmacotherapy, Epidemiology and Economics, Department of Pharmacy, University of Groningen, Groningen, The Netherlands
| | - Elisabeth H Bel
- Department of Respiratory Medicine, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, The Netherlands
| | - Anneke Ten Brinke
- Department of Pulmonology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
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Visser CD, Linthorst JM, Kuipers E, Sont JK, Lacroix JPW, Guchelaar HJ, Teichert M. Respiratory Adherence Care Enhancer Questionnaire: Identifying Self-Management Barriers of Inhalation Corticosteroids in Asthma. Front Pharmacol 2022; 12:767092. [PMID: 35002706 PMCID: PMC8729223 DOI: 10.3389/fphar.2021.767092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Suboptimal self-management of inhaled corticosteroids (ICS) in asthma patients is frequently observed in clinical practice and associated with poor asthma control. Driving factors for suboptimal self-management are complex and consist of a range of behavioral barriers (cognitive, affective and practical) with a considerable inter-individual variability. Identification of individual barriers facilitates the use of corresponding behavior change techniques and tailored care to improve asthma treatment outcomes. Objective: This study describes the development and validation of the 'Respiratory Adherence Care Enhancer' (RACE) questionnaire to identify individual barriers to self-management of ICS therapy in asthma patients. Methods: The development included: 1) an inventory of self-management barriers based on a literature review, 2) expert assessment on relevance and completeness of this set, linking these barriers to behavioral domains of the Theoretical Domains Framework (TDF) and 3) the formulation of corresponding questions assessing each of the barriers. A cross-sectional study was performed for validation. Primary care asthma patients were invited to fill out the RACE-questionnaire prior to a semi-structured telephonic interview as golden standard. Barriers detected from the questionnaire were compared to those mentioned in the interview. Results: The developed questionnaire is made up of 6 TDF-domains, covering 10 self-management barriers with 23 questions. For the validation 64 patients completed the questionnaire, of whom 61 patients were interviewed. Cronbach's alpha for the consistency of questions within the barriers ranged from 0.58 to 0.90. Optimal cut-off values for the presence of barriers were determined at a specificity between 67 and 92% with a sensitivity between 41 and 83%. Significant Areas Under the Receiver Operating Curves values were observed for 9 barriers with values between 0.69 and 0.86 (p-value <0.05), except for 'Knowledge of ICS medication' with an insignificant value of 0.53. Conclusion: The RACE-questionnaire yields adequate psychometric characteristics to identify individual barriers to self-management of ICS therapy in asthma patients, facilitating tailored care.
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Affiliation(s)
- Claire D Visser
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Jip M Linthorst
- Royal Dutch Pharmacists Association (KNMP), The Hague, Netherlands
| | | | - Jacob K Sont
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, Netherlands
| | - Joyca P W Lacroix
- Department of Digital Engagement, Behavior and Cognition, Philips Research, Eindhoven, Netherlands
| | - Henk-Jan Guchelaar
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands
| | - Martina Teichert
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Netherlands.,Royal Dutch Pharmacists Association (KNMP), The Hague, Netherlands
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16
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Ruissen MM, Sont JK, van Vugt HA, Kunneman M, Rutten GEHM, de Koning EJP. Key Factors Relevant for Healthcare Decisions of Patients with Type 1 and Type 2 Diabetes in Secondary Care According to Healthcare Professionals. Patient Prefer Adherence 2022; 16:809-819. [PMID: 35370405 PMCID: PMC8974434 DOI: 10.2147/ppa.s354686] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 03/11/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Understanding which factors are important for healthcare decisions of patients with diabetes in clinical practice is important to personalise diabetes care strategies and tailor care plans to the individual. The main drivers for these healthcare decisions remain unclear. This study assessed which key factors are relevant for healthcare decisions during clinical consultations for patients with type 1 diabetes (T1DM) and type 2 diabetes (T2DM), according to healthcare professionals. MATERIALS AND METHODS Annual diabetes reviews were performed as part of a trial assessing the impact of a consultation model facilitating person-centred diabetes care in six hospital outpatient clinics. After each consultation, we asked healthcare professionals to choose a maximum of three out of 20 factors that were most relevant for healthcare decisions about treatment goals and the professional support needed during the upcoming year. Factors were characterised as either person or disease-related. Percentages reflect the number of annual diabetes reviews in which the key factor was reported. RESULTS Seventeen physicians and eight diabetes specialist nurses reported the key factors relevant for healthcare decisions in 285 annual diabetes reviews (T1DM n = 119, T2DM n = 166). Healthcare professionals most often reported quality of life (31.9%), motivation (27.0%) and diabetes self-management (25.6%), and to a lesser extent glycaemic control (24.2%), to be important for decisions about treatment goals. For decisions about the professional support needed during the upcoming year patient's preferences (33.7%), diabetes self-management (33.3%), quality of life (27.0%) and motivation (25.6%) were most often considered relevant by healthcare professionals. CONCLUSION According to healthcare professionals, person-related factors such as quality of life, diabetes self-management and motivation are predominantly relevant for healthcare decisions about treatment goals and the professional support needed during the upcoming year.
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Affiliation(s)
- Merel M Ruissen
- Department of Medicine, Leiden University Medical Centre, Leiden, the Netherlands
- Department of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Jacob K Sont
- Department of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
| | - Heidi A van Vugt
- Julius Centre for Health Sciences and Primary Care, Department of General Practice, University Medical Centre Utrecht, Utrecht, the Netherlands
- Dutch Diabetes Federation, Amersfoort, the Netherlands
| | - Marleen Kunneman
- Department of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN, USA
| | - Guy E H M Rutten
- Julius Centre for Health Sciences and Primary Care, Department of General Practice, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Eelco J P de Koning
- Department of Medicine, Leiden University Medical Centre, Leiden, the Netherlands
- Correspondence: Eelco JP de Koning, Department of Medicine, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, the Netherlands, Tel +31 71 52 62085, Fax +31 71 52 66881, Email
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17
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Beerthuizen T, Rikkers-Mutsaerts ERVM, Snoeck-Stroband JB, Sont JK. The Role of Education, Monitoring, and Symptom Perception in Internet-Based Self-management Among Adolescents With Asthma: Secondary Analysis of a Randomized Controlled Trial. JMIR Pediatr Parent 2021; 4:e17959. [PMID: 34879001 PMCID: PMC8693204 DOI: 10.2196/17959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 12/31/2020] [Accepted: 06/01/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Internet-based self-management programs improve asthma control and the asthma-related quality of life in adults and adolescents. The components of self-management programs include education and the web-based self-monitoring of symptoms; the latter requires adequate perception in order to timely adjust lifestyle or medication or to contact a care provider. OBJECTIVE We aimed to test the hypothesis that adherence to education and web-based monitoring and adequate symptom perception are important determinants for the improvement of asthma control in self-management programs. METHODS We conducted a subgroup analysis of the intervention group of a randomized controlled trial, which included adolescents who participated in the internet-based self-management arm. We assessed the impacts that attendance in education sessions, the frequency of web-based monitoring, and the level of perception had on changes in asthma control (Asthma Control Questionnaire [ACQ]) and asthma-related quality of life (Pediatric Asthma Quality of Life Questionnaire) from baseline to 12 months after intervention. RESULTS Adolescents who attended education sessions had significant and clinically relevant improvements in asthma control (ACQ score difference: -0.6; P=.03) and exhibited a nonsignificant trend of improvement in asthma-related quality of life (Pediatric Asthma Quality of Life Questionnaire score difference: -0.45; P=.15) when compared to those who did not adhere to education. Frequent monitoring alone did not improve asthma control (P=.07) and quality of life (P=.44) significantly, but its combination with education did result in improved ACQ scores (difference: -0.88; P=.02). There were no significant differences in outcomes between normoperceivers and hypoperceivers. CONCLUSIONS Education, especially in combination with frequent web-based monitoring, is an important determinant for the 1-year outcomes of asthma control in internet-based self-management programs for adolescents with partly controlled and uncontrolled asthma; however, we could not establish the effect of symptom perception. This study provides important knowledge on the effects of asthma education and monitoring in daily life.
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Affiliation(s)
- Thijs Beerthuizen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, Netherlands
| | | | - Jiska B Snoeck-Stroband
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, Netherlands
| | - Jacob K Sont
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Leiden, Netherlands
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18
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Glachs D, Namli T, Strohmeier F, Rodríguez Suárez G, Sluis M, Delgado-Lista J, Sont JK, de Graaf AA, Salzsieder E, Vogt L. A Predictive Model-Based Decision Support System for Diabetes Patient Empowerment. Stud Health Technol Inform 2021; 281:963-968. [PMID: 34042816 DOI: 10.3233/shti210321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
The main objective of POWER2DM is to develop and validate a personalized self-management support system (SMSS) for T1 and T2 diabetes patients that combines and integrates i) a decision support system (DSS) based on leading European predictive personalized models for diabetes interlinked with predictive computer models, ii) automated e-coaching functionalities based on Behavioral Change Theories, and iii) real-time Personal Data processing and interpretation. The SMSS offers a guided workflow based on treatment goals and activities where a periodic review evaluates the patients progress and provides detailed feedback on how to improve towards a healthier, diabetes appropriate lifestyle.
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Affiliation(s)
- Dietmar Glachs
- Salzburg Research Forschungsgesellschaft, Salzburg, Austria
| | - Tuncay Namli
- Software Research & Development and Consultancy Corp., Ankara, Turkey
| | | | | | | | | | - Jacob K Sont
- Leiden University Medical Center, Leiden, Netherlands
| | - Albert A de Graaf
- Dep. Risk Analysis for Products in Development, TNO, Utrecht, Netherlands
| | | | - Lutz Vogt
- Institute of Diabetes "Gerhard Katsch" Karlsburg, Karlsburg, Germany
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19
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Cardol CK, Tommel J, van Middendorp H, Ciere Y, Sont JK, Evers AWM, van Dijk S. Detecting and Treating Psychosocial and Lifestyle-Related Difficulties in Chronic Disease: Development and Treatment Protocol of the E-GOAL eHealth Care Pathway. Int J Environ Res Public Health 2021; 18:3292. [PMID: 33806724 PMCID: PMC8005221 DOI: 10.3390/ijerph18063292] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/18/2021] [Accepted: 03/19/2021] [Indexed: 01/19/2023]
Abstract
Many patients with lifestyle-related chronic diseases find it difficult to adhere to a healthy and active lifestyle, often due to psychosocial difficulties. The aim of the current study was to develop an eHealth care pathway aimed at detecting and treating psychosocial and lifestyle-related difficulties that fits the needs and preferences of individual patients across various lifestyle-related chronic diseases. Each intervention component was developed by (1) developing initial versions based on scientific evidence and/or the Behavior Change Wheel; (2) co-creation: acquiring feedback from patients and health professionals; and (3) refining to address users' needs. In the final eHealth care pathway, patients complete brief online screening questionnaires to detect psychosocial and lifestyle-related difficulties, i.e., increased-risk profiles. Scores are visualized in personal profile charts. Patients with increased-risk profiles receive complementary questionnaires to tailor a 3-month guided web-based cognitive behavioral therapy intervention to their priorities and goals. Progress is assessed with the screening tool. This systematic development process with a theory-based framework and co-creation methods resulted in a personalized eHealth care pathway that aids patients to overcome psychosocial barriers and adopt a healthy lifestyle. Prior to implementation in healthcare, randomized controlled trials will be conducted to evaluate its cost-effectiveness and effectiveness on psychosocial, lifestyle, and health-related outcomes.
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Affiliation(s)
- Cinderella K. Cardol
- Health, Medical and Neuropsychology Unit, Leiden University, 2333 AK Leiden, The Netherlands; (J.T.); (H.v.M.); (Y.C.); (A.W.M.E.); (S.v.D.)
| | - Judith Tommel
- Health, Medical and Neuropsychology Unit, Leiden University, 2333 AK Leiden, The Netherlands; (J.T.); (H.v.M.); (Y.C.); (A.W.M.E.); (S.v.D.)
| | - Henriët van Middendorp
- Health, Medical and Neuropsychology Unit, Leiden University, 2333 AK Leiden, The Netherlands; (J.T.); (H.v.M.); (Y.C.); (A.W.M.E.); (S.v.D.)
| | - Yvette Ciere
- Health, Medical and Neuropsychology Unit, Leiden University, 2333 AK Leiden, The Netherlands; (J.T.); (H.v.M.); (Y.C.); (A.W.M.E.); (S.v.D.)
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Jacob K. Sont
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands;
| | - Andrea W. M. Evers
- Health, Medical and Neuropsychology Unit, Leiden University, 2333 AK Leiden, The Netherlands; (J.T.); (H.v.M.); (Y.C.); (A.W.M.E.); (S.v.D.)
- Healthy Society, Medical Delta, 2629 JH Delft, The Netherlands
| | - Sandra van Dijk
- Health, Medical and Neuropsychology Unit, Leiden University, 2333 AK Leiden, The Netherlands; (J.T.); (H.v.M.); (Y.C.); (A.W.M.E.); (S.v.D.)
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20
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Uitbeijerse BS, Nijhoff MF, Sont JK, de Koning EJP. Fasting parameters for estimation of stimulated β cell function in islet transplant recipients with or without basal insulin treatment. Am J Transplant 2021; 21:297-306. [PMID: 32524720 PMCID: PMC7818182 DOI: 10.1111/ajt.16135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/11/2020] [Accepted: 05/27/2020] [Indexed: 01/25/2023]
Abstract
In order to assess β cell secretory capacity after islet transplantation, standardized mixed meal stimulation tests are often used. But these tests are cumbersome and the effect of exogenous insulin on the test results is unclear. The aim of our study was to determine to what extent fasting glycemic indices can estimate stimulated β cell function in islet transplant recipients with and without basal insulin. In total 100 mixed meal stimulation tests, including 31 with concurrent basal insulin treatment, were performed in 36 islet transplant recipients. In a multivariate model, fasting C-peptide and fasting glucose together estimated peak C-peptide with R2 = .87 and area under the curve (AUC) C-peptide with a R2 = .93. There was a larger increase of glucose during tests in which exogenous insulin was used (+7.9 vs +5.3 mmol/L, P < .001) and exogenous insulin use was associated with a slightly lower estimated peak C-peptide (relative change: -15%, P = .02). In islet transplant recipients the combination of fasting C-peptide and glucose can be used to accurately estimate stimulated β cell function after a mixed meal stimulation test, whether exogenous basal insulin is present or not. These data indicate that graft function can be reliably determined during exogenous insulin treatment and that regular islet graft stimulation tests can be minimized.
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Affiliation(s)
- Bas S. Uitbeijerse
- Department of Internal MedicineLeiden University Medical CenterLeidenthe Netherlands
| | - Michiel F. Nijhoff
- Department of Internal MedicineLeiden University Medical CenterLeidenthe Netherlands
| | - Jacob K. Sont
- Department of Biomedical Data SciencesSection Medical Decision MakingLeiden University Medical CenterLeidenthe Netherlands
| | - Eelco J. P. de Koning
- Department of Internal MedicineLeiden University Medical CenterLeidenthe Netherlands
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21
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Boer S, Honkoop PJ, Loijmans RJB, Snoeck-Stroband JB, Assendelft WJJ, Schermer TRJ, Sont JK. Personalised exhaled nitric oxygen fraction ( F ENO)-driven asthma management in primary care: a F ENO subgroup analysis of the ACCURATE trial. ERJ Open Res 2020; 6:00351-2019. [PMID: 32963989 PMCID: PMC7487343 DOI: 10.1183/23120541.00351-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/24/2020] [Indexed: 01/19/2023] Open
Abstract
Background The aim of this study was to identify patients who benefit most from exhaled nitric oxide fraction (FENO)-driven asthma management in primary care, based on prespecified subgroups with different levels of FENO. Methods We used data from 179 adults with asthma from a 12-month primary care randomised controlled trial with 3-monthly assessments of FENO, asthma control, medication usage, costs of medication, severe asthma exacerbations and quality of life. In the original study, patients were randomised to either a symptom-driven treatment strategy (controlled asthma (Ca) strategy) or a FENO+symptom-driven strategy (FCa). In both groups, patients were categorised by their baseline level of FENO as low (<25 ppb), intermediate (25–50 ppb) and high (>50 ppb). At 12 months, we compared, for each prespecified FENO subgroup, asthma control, asthma-related quality of life, medication usage, and costs of medication between the Ca and FCa strategy. Results We found a difference between the Ca and FCa strategy for the mean dosage of beclomethasone strategy of 223 µg (95% CI 6–439), p=0.04) and for the total costs of asthma medication a mean reduction of US$159 (95% CI US$33–285), p=0.03) in patients with a low baseline FENO level. No differences were found for asthma control, severe asthma exacerbations and asthma-related quality of life in patients with a low baseline FENO level. Furthermore, in patients with intermediate or high level of FENO, no differences were found. Conclusions In primary care, FENO-driven asthma management is effective in patients with a low FENO level, for whom it is possible to down-titrate medication, while preserving asthma control and quality of life. In primary care, FENO-driven asthma management is effective in patients with a low FENO, for whom it is possible to down-titrate medication while preserving asthma control and quality of lifehttps://bit.ly/2wC25N7d
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Affiliation(s)
- Suzanne Boer
- Dept of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands.,Dept of Clinical Epidemiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Persijn J Honkoop
- Dept of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - Rik J B Loijmans
- Dept of General Practice, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jiska B Snoeck-Stroband
- Dept of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - Willem J J Assendelft
- Dept of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Tjard R J Schermer
- Dept of Primary and Community Care, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jacob K Sont
- Dept of Biomedical Data Sciences, Section of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
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22
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Beerthuizen T, Rijssenbeek-Nouwens LH, van Koppen SM, Khusial RJ, Snoeck-Stroband JB, Sont JK. Internet-Based Self-Management Support After High-Altitude Climate Treatment for Severe Asthma: Randomized Controlled Trial. J Med Internet Res 2020; 22:e13145. [PMID: 32706692 PMCID: PMC7407281 DOI: 10.2196/13145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/29/2019] [Accepted: 03/29/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In patients with severe asthma, high-altitude climate treatment has been shown to improve asthma control. However, asthma symptoms and limitations may increase after finishing inpatient rehabilitation programs and returning to sea level. OBJECTIVE We assessed the effectiveness of a patient-tailored, internet-based, self-management strategy in addition to usual care after finishing high-altitude climate treatment. METHODS We performed a randomized controlled trial with a 1-year follow-up in patients from a high-altitude asthma center in Davos, Switzerland. At the end of a 12-week multidisciplinary rehabilitation program, 62 adults with asthma were randomized to receive either internet-based self-management support in addition to usual care (n=33) or usual care only after discharge (n=29). The endpoints were changes in asthma-related quality of life according to the Asthma Quality of Life Questionnaire (AQLQ) (a higher score is better) and asthma control according to the Asthma Control Questionnaire (ACQ) (a lower score is better), with a minimally important difference of 0.5 points for both. RESULTS Asthma-related quality of life and asthma control declined over time in the usual care strategy group, whereas there was a slower decline in the internet-based strategy group. For both endpoints, mixed-model analysis showed a significant positive effect in favor of internet-based self-management during follow-up (mean AQLQ score difference 0.39, 95% CI 0.092-0.69; P=.01 and ACQ score difference -0.50, 95% CI -0.86 to -0.15; P=.006), which was prominent among patients with uncontrolled asthma at discharge (AQLQ score difference 0.59, 95% CI 0.19-0.99; P=.003 and ACQ score difference -0.73, 95% CI -1.18 to -0.28; P=.002). CONCLUSIONS Internet-based self-management support was associated with a smaller decline in quality of life and asthma control as compared with usual care, especially in patients with lower asthma control, after completion of high-altitude climate treatment. Internet-based self-management support in adults with severe asthma seems feasible and effective to maintain quality of life and asthma control. TRIAL REGISTRATION The trial is registered in the Netherlands Trial Register (NTR1995).
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Affiliation(s)
- Thijs Beerthuizen
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, Netherlands
| | | | - Sophia M van Koppen
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, Netherlands
| | - Rishi J Khusial
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, Netherlands
| | - Jiska B Snoeck-Stroband
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, Netherlands
| | - Jacob K Sont
- Department of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, Netherlands
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23
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Türk Y, Theel W, van Huisstede A, van de Geijn GJM, Birnie E, Hiemstra PS, Sont JK, Taube C, Braunstahl GJ. Short-term and long-term effect of a high-intensity pulmonary rehabilitation programme in obese patients with asthma: a randomised controlled trial. Eur Respir J 2020; 56:13993003.01820-2019. [PMID: 32299852 DOI: 10.1183/13993003.01820-2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 03/16/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To determine the short-term and long-term effects of a high intensity pulmonary rehabilitation programme on asthma control, body composition, lung function and exercise capacity in obese asthma patients. METHODS Patients with obesity (body mass index (BMI)≥30 kg·m-2) and suboptimal controlled asthma (Asthma Control Questionnaire (ACQ)≥0.75) were randomly assigned to a 3-month pulmonary rehabilitation programme (PR only), pulmonary rehabilitation programme with the use of an internet based self-management support programme (PR+SMS) or usual care. The pulmonary rehabilitation programme included high-intensity interval training, nutritional intervention and psychological group sessions. Patients in the usual care group were advised to lose weight and to exercise. The primary outcome was the difference of change of ACQ between PR only and PR+SMS after 3 months. Total follow-up was 12 months. RESULTS 34 patients were included in the study (14 PR only, nine PR+SMS, 11 control). Compared with patients in usual care, patients in the PR only group had a significant reduction in BMI and significant improvements in asthma control, exercise capacity and aerobic capacity after 3 months. These improvements persisted during 12 months of follow-up. No difference in ACQ between PR+SMS and PR only groups was observed. However, users of the SMS programme had a significantly lower BMI after 12 months compared with subjects in the PR only group. CONCLUSION A high-intensity pulmonary rehabilitation programme provides sustained improvements in asthma control, body composition and exercise capacity in obese asthmatics that are not optimally controlled and, therefore, should be considered in the treatment of these patients.
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Affiliation(s)
- Yasemin Türk
- Dept of Pulmonology Franciscus Gasthuis & Vlietland Rotterdam The Netherlands
| | - Willy Theel
- Dept of Physiotherapy, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Astrid van Huisstede
- Dept of Pulmonology Franciscus Gasthuis & Vlietland Rotterdam The Netherlands.,Dept of Pulmonology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Gert-Jan M van de Geijn
- Dept of Clinical Chemistry, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands.,Dept of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Erwin Birnie
- Dept of Genetics, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Dept of Statistics and Education, Francis Academy, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
| | - Pieter S Hiemstra
- Dept of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacob K Sont
- Dept of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Christian Taube
- Dept of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands.,Dept of Pulmonary Medicine, University Hospital Essen - Ruhrlandklinik, Essen, Germany
| | - Gert-Jan Braunstahl
- Dept of Pulmonology Franciscus Gasthuis & Vlietland Rotterdam The Netherlands.,Dept of Pulmonology, Erasmus Medical Center, Rotterdam, The Netherlands
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24
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Khusial RJ, Honkoop PJ, van der Meer V, Snoeck-Stroband JB, Sont JK. Validation of online Asthma Control Questionnaire and Asthma Quality of Life Questionnaire. ERJ Open Res 2020; 6:00289-2019. [PMID: 32010723 PMCID: PMC6983500 DOI: 10.1183/23120541.00289-2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/27/2019] [Indexed: 11/21/2022] Open
Abstract
Objective Several newly developed eHealth applications use online questionnaires to monitor asthma control. The Asthma Control Questionnaire (ACQ) and Asthma Quality of Life Questionnaire (AQLQ) are two such commonly used questionnaires. These questionnaires are validated for use on paper. This study aims to validate them by assessing the agreement between online and paper versions of the ACQ and AQLQ. Methods Patients (aged 18 years and older) from the Self-Management in Asthma Supported by Hospitals, ICT, Nurses and General Practitioners (SMASHING)-trial and Davos@home study were included in this study. Patients completed both the paper and online Dutch versions of the ACQ and AQLQ in a random order within a 2-week interval. Agreement between the different versions was assessed with paired t-tests, intraclass correlation coefficients and Bland–Altman plots. Results In total 44 patients were eligible for analysis. The mean difference between the paper and online versions of the ACQ was 0.04 (p=0.40) and for the AQLQ it was 0.08 (p=0.06). The intraclass correlation coefficient scores were 0.94 for the ACQ and 0.95 for the AQLQ. Conclusion The online versions of the ACQ and AQLQ show high levels of agreement with the paper versions and can therefore be safely used in eHealth applications to respectively monitor asthma control and quality of life. The self-administered online versions of the Asthma Control Questionnaire and Asthma Quality of Life Questionnaire show good agreement with the paper versions, and are therefore, valid measurement tools in eHealth applicationshttp://bit.ly/2rGBbRf
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Affiliation(s)
- Rishi J Khusial
- Dept of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Persijn J Honkoop
- Dept of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Victor van der Meer
- Dept of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Jiska B Snoeck-Stroband
- Dept of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacob K Sont
- Dept of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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25
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van Bragt JJMH, Adcock IM, Bel EHD, Braunstahl GJ, Ten Brinke A, Busby J, Canonica GW, Cao H, Chung KF, Csoma Z, Dahlén B, Davin E, Hansen S, Heffler E, Horvath I, Korn S, Kots M, Kuna P, Kwon N, Louis R, Plaza V, Porsbjerg C, Ramos-Barbon D, Richards LB, Škrgat S, Sont JK, Vijverberg SJH, Weersink EJM, Yasinska V, Wagers SS, Djukanovic R, Maitland-van der Zee AH. Characteristics and treatment regimens across ERS SHARP severe asthma registries. Eur Respir J 2020; 55:13993003.01163-2019. [PMID: 31601713 DOI: 10.1183/13993003.01163-2019] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 09/18/2019] [Indexed: 11/05/2022]
Abstract
Little is known about the characteristics and treatments of patients with severe asthma across Europe, but both are likely to vary. This is the first study in the European Respiratory Society Severe Heterogeneous Asthma Research collaboration, Patient-centred (SHARP) Clinical Research Collaboration and it is designed to explore these variations. Therefore, we aimed to compare characteristics of patients in European severe asthma registries and treatments before starting biologicals.This was a cross-sectional retrospective analysis of aggregated data from 11 national severe asthma registries that joined SHARP with established patient databases.Analysis of data from 3236 patients showed many differences in characteristics and lifestyle factors. Current smokers ranged from 0% (Poland and Sweden) to 9.5% (Belgium), mean body mass index ranged from 26.2 (Italy) to 30.6 kg·m-2 (the UK) and the largest difference in mean pre-bronchodilator forced expiratory volume in 1 s % predicted was 20.9% (the Netherlands versus Hungary). Before starting biologicals patients were treated differently between countries: mean inhaled corticosteroid dose ranged from 700 to 1335 µg·day-1 between those from Slovenia versus Poland when starting anti-interleukin (IL)-5 antibody and from 772 to 1344 µg·day-1 in those starting anti-IgE (Slovenia versus Spain). Maintenance oral corticosteroid use ranged from 21.0% (Belgium) to 63.0% (Sweden) and from 9.1% (Denmark) to 56.1% (the UK) in patients starting anti-IL-5 and anti-IgE, respectively.The severe asthmatic population in Europe is heterogeneous and differs in both clinical characteristics and treatment, often appearing not to comply with the current European Respiratory Society/American Thoracic Society guidelines definition of severe asthma. Treatment regimens before starting biologicals were different from inclusion criteria in clinical trials and varied between countries.
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Affiliation(s)
- Job J M H van Bragt
- Dept of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Ian M Adcock
- Molecular Cell Biology Group, National Heart and Lung Institute, Imperial College London, London, UK
| | - Elisabeth H D Bel
- Dept of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | | | - John Busby
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Giorgio W Canonica
- Personalised Medicine Clinic, Asthma and Allergy, Humanitas Clinical and Research Centre, Humanitas University, Rozzano and SANI-Severe Asthma Network Italy, Milan, Italy
| | - Hui Cao
- Novartis Pharmaceuticals, East Hanover, NJ, USA
| | - Kian Fan Chung
- Experimental Studies Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Zsuzsanna Csoma
- National Koranyi Institute of Pulmonology, Budapest, Hungary
| | - Barbro Dahlén
- Division of Respiratory Medicine and Allergy, Dept of Medicine, Karolinska University Hospital, Huddinge, Sweden
| | | | - Susanne Hansen
- Center for Clinical Research and Disease Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Enrico Heffler
- Personalised Medicine Clinic, Asthma and Allergy, Humanitas Clinical and Research Centre, Humanitas University, Rozzano and SANI-Severe Asthma Network Italy, Milan, Italy
| | - Ildiko Horvath
- National Koranyi Institute of Pulmonology, Budapest, Hungary
| | | | - Maxim Kots
- Global Clinical Development, Chiesi Farmaceutici, Parma, Italy
| | - Piotr Kuna
- Dept of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Namhee Kwon
- Respiratory Medical Franchise, GSK, Brentford, UK
| | - Renaud Louis
- Dept of Pulmonary Medicine, Centre Hospitalier Universitaire, GIGA-I3 Research Group, Liege University, Liege, Belgium
| | - Vicente Plaza
- Respiratory Medicine Dept and Biomedical Research Institute, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Celeste Porsbjerg
- Respiratory Research Unit, Dept of Respiratory Medicine, Bispebjerg University Hospital, Copenhagen, Denmark
| | - David Ramos-Barbon
- Respiratory Medicine Dept and Biomedical Research Institute, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Levi B Richards
- Dept of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Sabina Škrgat
- University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
| | - Jacob K Sont
- Dept of Biomedical Data Sciences, Section Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Susanne J H Vijverberg
- Dept of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Els J M Weersink
- Dept of Respiratory Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Valentyna Yasinska
- Division of Respiratory Medicine and Allergy, Dept of Medicine, Karolinska University Hospital, Huddinge, Sweden
| | | | - Ratko Djukanovic
- NIHR Southampton Respiratory Biomedical Research Unit, Faculty of Medicine, University of Southampton, Southampton, UK
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Boer S, Sont JK, Loijmans RJB, Snoeck-Stroband JB, Ter Riet G, Schermer TRJ, Assendelft WJJ, Honkoop PJ. Development and Validation of Personalized Prediction to Estimate Future Risk of Severe Exacerbations and Uncontrolled Asthma in Patients with Asthma, Using Clinical Parameters and Early Treatment Response. J Allergy Clin Immunol Pract 2018; 7:175-182.e5. [PMID: 29936188 DOI: 10.1016/j.jaip.2018.06.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 05/07/2018] [Accepted: 06/04/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Current level of asthma control can be easily assessed by validated instruments, but it is currently difficult to assess individuals' level of future risk. OBJECTIVE Develop, and validate, a risk prediction score for level of future risk, including patient characteristics and information on early treatment response. METHODS We used data of 304 adult patients with asthma from a 12-month primary care randomized controlled trial with 3-monthly assessments. With logistic regression we modeled the association between the level of future risk and patient characteristics including early treatment response. Future risk was defined as Asthma Control Questionnaire (ACQ) score of 1.5 or more at 12 months or the experience of at least 1 exacerbation during the final 6 months. We developed a risk prediction score on the basis of regression coefficients. RESULTS Performance of the risk prediction score improved, taking into account data on early treatment response (area under receiver-operating curve [AUROC] = 0.84) compared with a model containing only baseline characteristics (AUROC = 0.78). The score includes 6 easy-to-obtain predictors: sex, ACQ score and exacerbations in the previous year at baseline and at first follow-up, and smoking status and exacerbations in the previous 3 months (indicating early treatment response). External validation yielded an AUROC of 0.77. The risk prediction score classified patients into 3 risk groups: low (absolute risk, 11.7%), intermediate (47.0%), and high (72.7%). CONCLUSIONS We developed and externally validated a risk prediction score, quantifying both level of current asthma control and the guideline-defined future risk. Patients' individual risk can now be estimated in an easy way, as proposed but not specified, by asthma management guidelines.
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Affiliation(s)
- Suzanne Boer
- Department of Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands; Department of Clinical Epidemiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Jacob K Sont
- Department of Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
| | - Rik J B Loijmans
- Department of General Practice, Academic Medical Centre, Amsterdam, the Netherlands
| | - Jiska B Snoeck-Stroband
- Department of Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands
| | - Gerben Ter Riet
- Department of General Practice, Academic Medical Centre, Amsterdam, the Netherlands
| | - Tjard R J Schermer
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Persijn J Honkoop
- Department of Medical Decision Making, Leiden University Medical Centre, Leiden, the Netherlands.
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Loymans RJB, Debray TPA, Honkoop PJ, Termeer EH, Snoeck-Stroband JB, Schermer TRJ, Assendelft WJJ, Timp M, Chung KF, Sousa AR, Sont JK, Sterk PJ, Reddel HK, Ter Riet G. Exacerbations in Adults with Asthma: A Systematic Review and External Validation of Prediction Models. J Allergy Clin Immunol Pract 2018; 6:1942-1952.e15. [PMID: 29454163 DOI: 10.1016/j.jaip.2018.02.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/11/2018] [Accepted: 02/05/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Several prediction models assessing future risk of exacerbations in adult patients with asthma have been published. Applicability of these models is uncertain because their predictive performance has often not been assessed beyond the population in which they were derived. OBJECTIVE This study aimed to identify and critically appraise prediction models for asthma exacerbations and validate them in 2 clinically distinct populations. METHODS PubMed and EMBASE were searched to April 2017 for reports describing adult asthma populations in which multivariable models were constructed to predict exacerbations during any time frame. After critical appraisal, the models' predictive performances were assessed in a primary and a secondary care population for author-defined exacerbations and for American Thoracic Society/European Respiratory Society-defined severe exacerbations. RESULTS We found 12 reports from which 24 prediction models were evaluated. Three predictors (previous health care utilization, symptoms, and spirometry values) were retained in most models. Assessment was hampered by suboptimal methodology and reporting, and by differences in exacerbation outcomes. Discrimination (area under the receiver-operating characteristic curve [c-statistic]) of models for author-defined exacerbations was better in the primary care population (mean, 0.71) than in the secondary care population (mean, 0.60) and similar (0.65 and 0.62, respectively) for American Thoracic Society/European Respiratory Society-defined severe exacerbations. Model calibration was generally poor, but consistent between the 2 populations. CONCLUSIONS The preservation of 3 predictors in models derived from variable populations and the fairly consistent predictive properties of most models in 2 distinct validation populations suggest the feasibility of a generalizable model predicting severe exacerbations. Nevertheless, improvement of the models is warranted because predictive performances are below the desired level.
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Affiliation(s)
- Rik J B Loymans
- Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands.
| | - Thomas P A Debray
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands; Cochrane Netherlands, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Persijn J Honkoop
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Evelien H Termeer
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Jiska B Snoeck-Stroband
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Tjard R J Schermer
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Willem J J Assendelft
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Merel Timp
- Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands
| | - Kian Fan Chung
- Experimental Airway Disease, National Heart and Lung Institute, Imperial College, London, United Kingdom; Royal Brompton NIHR Biomedical Research Unit, London, United Kingdom
| | - Ana R Sousa
- Respiratory Therapeutic Unit, GlaxoSmithKline, Uxbridge, United Kingdom
| | - Jacob K Sont
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter J Sterk
- Department of Respiratory Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Helen K Reddel
- Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Gerben Ter Riet
- Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands
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Kunz LI, ten Hacken NH, Lapperre TS, Timens W, Kerstjens HA, van Schadewijk A, Vonk JM, Sont JK, Snoeck-Stroband JB, Postma DS, Sterk P, Hiemstra PS. Airway inflammation in COPD after long-term withdrawal of inhaled corticosteroids. Eur Respir J 2017; 49:49/6/1700848. [DOI: 10.1183/13993003.00848-2017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 05/04/2017] [Indexed: 11/05/2022]
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Simpson AJ, Honkoop PJ, Kennington E, Snoeck-Stroband JB, Smith I, East J, Coleman C, Caress A, Chung KF, Sont JK, Usmani O, Fowler SJ. Perspectives of patients and healthcare professionals on mHealth for asthma self-management. Eur Respir J 2017; 49:49/5/1601966. [PMID: 28461291 DOI: 10.1183/13993003.01966-2016] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 02/07/2017] [Indexed: 11/05/2022]
Abstract
Mobile healthcare (mHealth) has the potential to revolutionise the self-management of long-term medical conditions such as asthma. A user-centred design is integral if mHealth is to be embraced by patients and healthcare professionals.The aim of this study was to determine the perspectives of individuals with asthma and healthcare professionals on the use of mHealth for asthma self-management.We used a sequential exploratory mixed methods design; focus groups informed the development of questionnaires, which were disseminated to individuals with asthma and healthcare professionals.Focus group participants (18 asthma patients and five healthcare professionals) identified 12 potential uses of mHealth. Questionnaire results showed that individuals with asthma (n=186) most frequently requested an mHealth system to monitor asthma over time (72%) and to collect data to present to healthcare teams (70%). In contrast, healthcare professionals (n=63) most frequently selected a system alerting patients to deteriorating asthma control (86%) and advising them when to seek medical attention (87%). Individuals with asthma were less likely than healthcare professionals (p<0.001) to believe that assessing medication adherence and inhaler technique could improve asthma control.Our data provide strong support for mHealth for asthma self-management, but highlight fundamental differences between the perspectives of patients and healthcare professionals.
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Affiliation(s)
- Andrew J Simpson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester and University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Persijn J Honkoop
- Dept of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Ian Smith
- Dept of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | | | | | - Ann Caress
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester and University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Kian Fan Chung
- National Heart and Lung Institute, Imperial College London and NIHR Biomedical Research Unit, Royal Brompton and Harefield NHS Trust, London, UK
| | - Jacob K Sont
- Dept of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - Omar Usmani
- National Heart and Lung Institute, Imperial College London and NIHR Biomedical Research Unit, Royal Brompton and Harefield NHS Trust, London, UK
| | - Stephen J Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester and University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
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Ammerlaan JW, van Os-Medendorp H, Sont JK, Elsworth GR, Osborne RH. Validation of the dutch version of the health education impact questionnaire (HEIQ) and comparison of the Dutch translation with the English, German and French HEIQ. Health Qual Life Outcomes 2017; 15:28. [PMID: 28143551 PMCID: PMC5282770 DOI: 10.1186/s12955-017-0601-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 01/19/2017] [Indexed: 11/11/2022] Open
Abstract
Background The Health Education Impact Questionnaire (heiQ) evaluates the effectiveness of health education and self-management programs provided to people dealing with a wide range of conditions. Aim of this study was to translate, culturally adapt and validate the Dutch translation of the heiQ and to compare the results with the English, German and French translations. Methods A systematic translation process was undertaken. Psychometric properties were studied among patients with arthritis, atopic dermatitis, food allergy and asthma (n = 286). Factorial validity using confirmatory factor analysis, item difficulty (D), item remainder correlation and composite reliability were conducted. Stability was tested using the intra-class correlation coefficient (ICC). Results Items were well understood and only minor language adjustments were required. Confirmatory fit indices were >0.95 and item difficulty was D ≥ 0.65 for all items in scales showing acceptable fit indices, except for the reversed Emotional distress scale. Composite reliability ranged between 0.67 and 0.85. Test-retest reliability (n = 93) ICC varied between 0.61 and 0.84. Comparisons with other translations showed comparable fit indices. A lower ICC on Self-monitoring and insight scale was observed. Conclusions The Dutch translation of the heiQ was found to be well understood and user friendly by patients with Rheumatoid Arthritis, Atopic Dermatitis, Food allergy and asthma and to have robust psychometric properties for evaluating the impact of health education and self-management programs. Given the wide applications of the heiQ and the comparability of the Dutch results with the English, German and French version, the heiQ is a practical and useful questionnaire to evaluate the impact of self-management support programs in different countries and populations with different diseases.
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Affiliation(s)
- Judy W Ammerlaan
- Department Rheumatology and Clinical Immunology, University Medical Center Utrecht, HPN D02.244, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Harmieke van Os-Medendorp
- Department Dermatology and Allergology, University Medical Center Utrecht, HPN D02.244, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Jacob K Sont
- Leiden University Medical Center, Department of Medical Decision Making, J10-86, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Gerald R Elsworth
- Health Systems Improvement Unit, School of Health and Social Development, Deakin University, Geelong, 3220, Australia
| | - Richard H Osborne
- Health Systems Improvement Unit, School of Health and Social Development, Deakin University, Geelong, 3220, Australia
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Honkoop PJ, Simpson A, Bonini M, Snoeck-Stroband JB, Meah S, Fan Chung K, Usmani OS, Fowler S, Sont JK. MyAirCoach: the use of home-monitoring and mHealth systems to predict deterioration in asthma control and the occurrence of asthma exacerbations; study protocol of an observational study. BMJ Open 2017; 7:e013935. [PMID: 28119390 PMCID: PMC5278295 DOI: 10.1136/bmjopen-2016-013935] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Asthma is a variable lung condition whereby patients experience periods of controlled and uncontrolled asthma symptoms. Patients who experience prolonged periods of uncontrolled asthma have a higher incidence of exacerbations and increased morbidity and mortality rates. The ability to determine and to predict levels of asthma control and the occurrence of exacerbations is crucial in asthma management. Therefore, we aimed to determine to what extent physiological, behavioural and environmental data, obtained by mobile healthcare (mHealth) and home-monitoring sensors, as well as patient characteristics, can be used to predict episodes of uncontrolled asthma and the onset of asthma exacerbations. METHODS AND ANALYSIS In an 1-year observational study, patients will be provided with mHealth and home-monitoring systems to record daily measurements for the first-month (phase I) and weekly measurements during a follow-up period of 11 months (phase II). Our study population consists of 150 patients, aged ≥18 years, with a clinician's diagnosis of asthma, currently on controller medication, with uncontrolled asthma and/or minimally one exacerbation in the past 12 months. They will be enrolled over three participating centres, including Leiden, London and Manchester. Our main outcomes are the association between physiological, behavioural and environmental data and (1) the loss of asthma control and (2) the occurrence of asthma exacerbations. ETHICS This study was approved by the Medical Ethics Committee of the Leiden University Medical Center in the Netherlands and by the NHS ethics service in the UK. TRIAL REGISTRATION NUMBER NCT02774772.
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Affiliation(s)
- Persijn J Honkoop
- Department of Quality of Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Andrew Simpson
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science and Centre, The University of Manchester University Hospital of South Manchester, NHS Foundation Trust, Manchester, UK
| | - Matteo Bonini
- National Heart and Lung Institute (NHLI), Imperial College London, London, UK
| | - Jiska B Snoeck-Stroband
- Department of Quality of Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Sally Meah
- National Heart and Lung Institute (NHLI), Imperial College London, London, UK
| | - Kian Fan Chung
- National Heart and Lung Institute (NHLI), Imperial College London, London, UK
| | - Omar S Usmani
- National Heart and Lung Institute (NHLI), Imperial College London, London, UK
| | - Stephen Fowler
- Centre for Respiratory Medicine and Allergy, Institute of Inflammation and Repair, Manchester Academic Health Science and Centre, The University of Manchester University Hospital of South Manchester, NHS Foundation Trust, Manchester, UK
| | - Jacob K Sont
- Department of Quality of Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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Kunz LI, ten Hacken NH, Lapperre TS, Timens W, Kerstjens HA, van Schadewijk A, Vonk JM, Sont JK, Snoeck-Stroband JB, Postma DS, Sterk PJ, Hiemstra PS. Airway inflammation in COPD after long-term withdrawal of inhaled corticosteroids. Eur Respir J 2016; 49:13993003.00839-2016. [DOI: 10.1183/13993003.00839-2016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 10/18/2016] [Indexed: 11/05/2022]
Abstract
Long-term treatment with inhaled corticosteroids (ICS) might attenuate lung function decline and decrease airway inflammation in a subset of patients with chronic obstructive pulmonary disease (COPD), and discontinuing ICS treatment could result in further lung function decline. We hypothesised that airway inflammation increases after ICS withdrawal following long-term ICS treatment in COPD.In the GLUCOLD-1 study (GL1), 114 patients with moderate-severe COPD were randomised to 6-month or 30-month treatment with fluticasone propionate (500 µg twice daily), 30-month treatment with fluticasone/salmeterol (500/50 µg twice daily) or placebo. During the 5-year follow-up study (GL2), patients were followed prospectively while being treated by their physician. Bronchial biopsies and induced sputum were collected at baseline, at 30 months (end of GL1) and at 7.5 years (end of GL2) to assess inflammatory cell counts. Data were analysed using linear mixed-effects models.In patients using ICS during GL1 and using ICS 0–50% of the time during GL2 (n=61/85), there were significant increases in GL2 bronchial CD3+ (fold change per year calculated as GL2 minus GL1 2.68, 95% CI 1.87–3.84), CD4+ (1.91, 95% CI 1.33–2.75) and CD8+ cells (1.71, 95% CI 1.15–2.53), and mast cells (1.91, 95% CI 1.36–2.68). The sputum total cell counts increased significantly in GL2 (1.90, 95% CI 1.42–2.54), as did counts of macrophages (2.10, 95% CI 1.55–2.86), neutrophils (1.92, 95% CI 1.39–2.65) and lymphocytes (2.01, 95% CI 1.46–2.78).ICS discontinuation increases airway inflammation in patients with moderate-severe COPD, suggesting that the anti-inflammatory effects of ICS in COPD are not maintained after ICS discontinuation.
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van Gaalen JL, van Bodegom-Vos L, Bakker MJ, Snoeck-Stroband JB, Sont JK. Internet-based self-management support for adults with asthma: a qualitative study among patients, general practitioners and practice nurses on barriers to implementation. BMJ Open 2016; 6:e010809. [PMID: 27566627 PMCID: PMC5013403 DOI: 10.1136/bmjopen-2015-010809] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES The aim of this study was to explore barriers among patients, general practitioners (GPs) and practice nurses to implement internet-based self-management support as provided by PatientCoach for asthma in primary care. SETTING Primary care within South Holland, the Netherlands. PARTICIPANTS Twenty-two patients (12 women, mean age 38 years), 21 GPs (6 women, mean age 52 years) and 13 practice nurses (all women, mean age 41 years). DESIGN A qualitative study using focus groups and interviews. OUTCOMES Barriers as perceived by patients, GPs and practice nurses to implementation of PatientCoach. METHODS 10 focus groups and 12 interviews were held to collect data: 4 patient focus groups, 4 GP focus groups, 2 practice nurse focus group, 2 patient interviews, 5 GP interviews and 5 practice nurse interviews. A prototype of PatientCoach that included modules for coaching, personalised information, asthma self-monitoring, medication treatment plan, feedback, e-consultations and a forum was demonstrated. A semistructured topic guide was used. Directed content analysis was used to analyse data. Reported barriers were classified according to a framework by Grol and Wensing. RESULTS A variety of barriers emerged among all participant groups. Barriers identified among patients include a lack of a patient-professional partnership in using PatientCoach and a lack of perceived benefit in improving asthma symptoms. Barriers identified among GPs include a low sense of urgency towards asthma care and current work routines. Practice nurses identified a low level of structured asthma care and a lack of support by colleagues as barriers. Among all participant groups, insufficient ease of use of PatientCoach, lack of financial arrangements and patient characteristics such as a lack of asthma symptoms were reported as barriers. CONCLUSIONS We identified a variety of barriers to implementation of PatientCoach. An effective implementation strategy for internet-based self-management support in asthma care should focus on these barriers.
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Affiliation(s)
- Johanna L van Gaalen
- Department of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - Moira J Bakker
- Department of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jiska B Snoeck-Stroband
- Department of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jacob K Sont
- Department of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
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den Otter I, Willems LNA, van Schadewijk A, van Wijngaarden S, Janssen K, de Jeu RC, Sont JK, Sterk PJ, Hiemstra PS. Lung function decline in asthma patients with elevated bronchial CD8, CD4 and CD3 cells. Eur Respir J 2016; 48:393-402. [PMID: 27230446 DOI: 10.1183/13993003.01525-2015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 04/04/2016] [Indexed: 11/05/2022]
Abstract
Which inflammatory markers in the bronchial mucosa of asthma patients are associated with decline of lung function during 14 years of prospective follow-up?To address this question, 19 mild-to-moderate, atopic asthmatic patients underwent spirometry and bronchoscopy at baseline and after 14 years of follow-up (t=14). Baseline bronchial biopsies were analysed for reticular layer thickness, eosinophil cationic protein (EG2), mast cell tryptase (AA1), CD3, CD4 and CD8. Follow-up biopsies were stained for EG2, AA1, neutrophil elastase, CD3, CD4, CD8, CD20, granzyme B, CD68, DC-SIGN, Ki67 and mucins.Decline in forced expiratory volume in 1 s (FEV1) % predicted was highest in patients with high CD8 (p=0.01, both pre- and post-bronchodilator) or high CD4 counts at baseline (p=0.04 pre-bronchodilator, p=0.03 post-bronchodilator). Patients with high CD8, CD3 or granzyme B counts at t=14 also exhibited faster decline in FEV1 (p=0.00 CD8 pre-bronchodilator, p=0.04 CD8 post-bronchodilator, p=0.01 granzyme B pre-bronchodilator, and p<0.01 CD3 pre-bronchodilator).Long-term lung function decline in asthma is associated with elevation of bronchial CD8 and CD4 at baseline, and CD8, CD3 and granzyme B at follow-up. This suggests that high-risk groups can be identified on the basis of inflammatory phenotypes.
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Affiliation(s)
- Irene den Otter
- Dept of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Luuk N A Willems
- Dept of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Kirsten Janssen
- Dept of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ronald C de Jeu
- Dept of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacob K Sont
- Dept of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter J Sterk
- Dept of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands Dept of Respiratory Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Pieter S Hiemstra
- Dept of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
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Beerthuizen T, Voorend-van Bergen S, van den Hout WB, Vaessen-Verberne AA, Brackel HJ, Landstra AM, van den Berg NJ, de Jongste JC, Merkus PJ, Pijnenburg MW, Sont JK. Cost-effectiveness of FENO-based and web-based monitoring in paediatric asthma management: a randomised controlled trial. Thorax 2016; 71:607-13. [PMID: 27048197 DOI: 10.1136/thoraxjnl-2015-207593] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 02/27/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND In children with asthma, web-based monitoring and inflammation-driven therapy may lead to improved asthma control and reduction in medications. However, the cost-effectiveness of these monitoring strategies is yet unknown. OBJECTIVE We assessed the cost-effectiveness of web-based monthly monitoring and of 4-monthly monitoring of FENO as compared with standard care. METHODS An economic evaluation was performed alongside a randomised controlled multicentre trial with a 1-year follow-up. Two hundred and seventy-two children with asthma, aged 4-18 years, were randomised to one of three strategies. In standard care, treatment was adapted according to Asthma Control Test (ACT) at 4-monthly visits, in the web-based strategy also according to web-ACT at 1 month intervals, and in the FENO-based strategy according to ACT and FENO at 4-monthly visits. Outcome measures were patient utilities, healthcare costs, societal costs and incremental cost per quality-adjusted life year (QALY) gained. RESULTS No statistically significant differences were found in QALYs and costs between the three strategies. The web-based strategy had 77% chance of being most cost-effective from a healthcare perspective at a willingness to pay a generally accepted €40 000/QALY. The FENO-based strategy had 83% chance of being most cost-effective at €40 000/QALY from a societal perspective. CONCLUSIONS Economically, web-based monitoring was preferred from a healthcare perspective, while the FENO-based strategy was preferred from a societal perspective, although in QALYs and costs no statistically significant changes were found as compared with standard care. As clinical outcomes also favoured the web-based and FENO-based strategies, these strategies may be useful additions to standard care. TRIAL REGISTRATION NUMBER Netherlands Trial Register (NTR1995).
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Affiliation(s)
- Thijs Beerthuizen
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Sandra Voorend-van Bergen
- Division Pediatric Respiratory Medicine, Department of Pediatrics, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Wilbert B van den Hout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Hein J Brackel
- Department of Pediatrics, Catharina Hospital, Eindhoven, The Netherlands
| | - Anneke M Landstra
- Department of Pediatrics, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Johan C de Jongste
- Division Pediatric Respiratory Medicine, Department of Pediatrics, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Peter J Merkus
- Department of Pediatric Pulmonology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mariëlle W Pijnenburg
- Division Pediatric Respiratory Medicine, Department of Pediatrics, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Jacob K Sont
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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Loymans RJB, Honkoop PJ, Termeer EH, Snoeck-Stroband JB, Assendelft WJJ, Schermer TRJ, Chung KF, Sousa AR, Sterk PJ, Reddel HK, Sont JK, Ter Riet G. Identifying patients at risk for severe exacerbations of asthma: development and external validation of a multivariable prediction model. Thorax 2016; 71:838-46. [PMID: 27044486 DOI: 10.1136/thoraxjnl-2015-208138] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 02/26/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Preventing exacerbations of asthma is a major goal in current guidelines. We aimed to develop a prediction model enabling practitioners to identify patients at risk of severe exacerbations who could potentially benefit from a change in management. METHODS We used data from a 12-month primary care pragmatic trial; candidate predictors were identified from GINA 2014 and selected with a multivariable bootstrapping procedure. Three models were constructed, based on: (1) history, (2) history+spirometry and (3) history+spirometry+FeNO. Final models were corrected for overoptimism by shrinking the regression coefficients; predictive performance was assessed by the area under the receiver operating characteristic curve (AUROC) and Hosmer-Lemeshow test. Models were externally validated in a data set including patients with severe asthma (Unbiased BIOmarkers in PREDiction of respiratory disease outcomes). RESULTS 80/611 (13.1%) participants experienced ≥1 severe exacerbation. Five predictors (Asthma Control Questionnaire score, current smoking, chronic sinusitis, previous hospital admission for asthma and ≥1 severe exacerbation in the previous year) were retained in the history model (AUROC 0.77 (95% CI 0.75 to 0.80); Hosmer-Lemeshow p value 0.35). Adding spirometry and FeNO subsequently improved discrimination slightly (AUROC 0.79 (95% CI 0.77 to 0.81) and 0.80 (95% CI 0.78 to 0.81), respectively). External validation yielded AUROCs of 0.69 (95% CI 0.63 to 0.75; 0.63 to 0.75 and 0.63 to 0.75) for the three models, respectively; calibration was best for the spirometry model. CONCLUSIONS A simple history-based model extended with spirometry identifies patients who are prone to asthma exacerbations. The additional value of FeNO is modest. These models merit an implementation study in clinical practice to assess their utility. TRIAL REGISTRATION NUMBER NTR 1756.
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Affiliation(s)
- Rik J B Loymans
- Department of General Practice, Academic Medical Center-University of Amsterdam (AMC), Amsterdam, The Netherlands
| | - Persijn J Honkoop
- LUMC Quality of Care Institute, Leiden University Medical Center (LUMC), Leiden, The Netherlands Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Evelien H Termeer
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre (RUNMC), Nijmegen, The Netherlands
| | - Jiska B Snoeck-Stroband
- LUMC Quality of Care Institute, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Willem J J Assendelft
- Department of Public Health and Primary Care, Leiden University Medical Center (LUMC), Leiden, The Netherlands Department of Primary and Community Care, Radboud University Nijmegen Medical Centre (RUNMC), Nijmegen, The Netherlands
| | - Tjard R J Schermer
- Department of Primary and Community Care, Radboud University Nijmegen Medical Centre (RUNMC), Nijmegen, The Netherlands
| | - Kian Fan Chung
- Experimental Airway Disease, National Heart and Lung Institute, Imperial College London & Royal Brompton NIHR Biomedical Research Unit, London, UK
| | - Ana R Sousa
- Respiratory Therapeutic Unit, GlaxoSmithKline, Stockley Park, UK
| | - Peter J Sterk
- Department of Respiratory Medicine, Academic Medical Center-University of Amsterdam (AMC), Amsterdam, The Netherlands
| | - Helen K Reddel
- Clinical Management Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Jacob K Sont
- LUMC Quality of Care Institute, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Gerben Ter Riet
- Department of General Practice, Academic Medical Center-University of Amsterdam (AMC), Amsterdam, The Netherlands
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Snoeck-Stroband JB, Lapperre TS, Sterk PJ, Hiemstra PS, Thiadens HA, Boezen HM, ten Hacken NHT, Kerstjens HAM, Postma DS, Timens W, Sont JK. Prediction of Long-Term Benefits of Inhaled Steroids by Phenotypic Markers in Moderate-to-Severe COPD: A Randomized Controlled Trial. PLoS One 2015; 10:e0143793. [PMID: 26659582 PMCID: PMC4699453 DOI: 10.1371/journal.pone.0143793] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Accepted: 11/09/2015] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND The decline in lung function can be reduced by long-term inhaled corticosteroid (ICS) treatment in subsets of patients with chronic obstructive pulmonary disease (COPD). We aimed to identify which clinical, physiological and non-invasive inflammatory characteristics predict the benefits of ICS on lung function decline in COPD. METHODS Analysis was performed in 50 steroid-naive compliant patients with moderate to severe COPD (postbronchodilator forced expiratory volume in one second (FEV1), 30-80% of predicted, compatible with GOLD stages II-III), age 45-75 years, >10 packyears smoking and without asthma. Patients were treated with fluticasone propionate (500 μg bid) or placebo for 2.5 years. Postbronchodilator FEV1, dyspnea and health status were measured every 3 months; lung volumes, airway hyperresponsiveness (PC20), and induced sputum at 0, 6 and 30 months. A linear mixed effect model was used for analysis of this hypothesis generating study. RESULTS Significant predictors of attenuated FEV1-decline by fluticasone treatment compared to placebo were: fewer packyears smoking, preserved diffusion capacity, limited hyperinflation and lower inflammatory cell counts in induced sputum (p<0.04). CONCLUSIONS Long-term benefits of ICS on lung function decline in patients with moderate-to-severe COPD are most pronounced in patients with fewer packyears, and less severe emphysema and inflammation. These data generate novel hypotheses on phenotype-driven therapy in COPD. TRIAL REGISTRATION ClinicalTrials.gov NCT00158847.
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Affiliation(s)
- Jiska B. Snoeck-Stroband
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
| | - Therese S. Lapperre
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter J. Sterk
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pieter S. Hiemstra
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Henk A. Thiadens
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - H. Marike Boezen
- University of Groningen, University Medical Center Groningen, Department of Epidemiology, Groningen, The Netherlands
| | - Nick H. T. ten Hacken
- University of Groningen, University Medical Center Groningen, Department of Pulmonology, Groningen, The Netherlands
| | - Huib A. M. Kerstjens
- University of Groningen, University Medical Center Groningen, Department of Pulmonology, Groningen, The Netherlands
| | - Dirkje S. Postma
- University of Groningen, University Medical Center Groningen, Department of Pulmonology, Groningen, The Netherlands
| | - Wim Timens
- University of Groningen, University Medical Center Groningen, Department of Pathology, Groningen, The Netherlands
| | - Jacob K. Sont
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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Vooijs M, Siemonsma PC, Heus I, Sont JK, Rövekamp TA, van Meeteren NL. Therapeutic validity and effectiveness of supervised physical exercise training on exercise capacity in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Clin Rehabil 2015; 30:1037-1048. [PMID: 26451006 DOI: 10.1177/0269215515609413] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Our aim was to determine the effectiveness of supervised physical exercise training on exercise capacity in patients with chronic obstructive pulmonary disease taken into consideration indices such as therapeutic validity of interventions, methodological quality of studies, and exercise volume. DATA RESOURCES MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, CINAHL, and PEDro databases were searched from inception until 17 July 2015 for randomized controlled trials comparing the effect of supervised exercise training vs. usual care in patients with chronic obstructive pulmonary disease. The references of included studies and review articles were hand searched for additional references and key authors of included trials were crosschecked in PubMed for any missed references. REVIEW METHODS Two reviewers independently assessed therapeutic validity of exercise training and methodological quality of included studies. Overall effects were calculated using a random effects model. RESULTS A total of 13 studies involving 756 patients with chronic obstructive pulmonary disease were included. Significant differences in maximal exercise capacity (standardized mean difference 0.52, 95% CI 0.31 to 0.74) and endurance exercise capacity (standardized mean difference 0.73, 95% CI 0.50 to 0.96) in favor of physical exercise training were found. The volume of physical exercise per week, the total volume of physical exercise, or their associations did not significantly influence the effect of training. CONCLUSION Effects of supervised physical exercise was not significantly altered by therapeutic validity. A combination of aerobic exercise and strength training was found to be more effective than strength training or endurance training alone in increasing the 6-minute walking distance.
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Affiliation(s)
- Martijn Vooijs
- 1 Department of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands.,2 Rijnlands Rehabilitation Centre, Leiden, The Netherlands.,3 TNO Healthy Living, Leiden, The Netherlands
| | | | - Inge Heus
- 2 Rijnlands Rehabilitation Centre, Leiden, The Netherlands
| | - Jacob K Sont
- 1 Department of Medical Decision Making, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Nico Lu van Meeteren
- 4 Department of Epidemiology and CAPHRI Research School, Maastricht University Medical Center, Maastricht, The Netherlands.,5 Health~Holland, Topsector Life Sciences and Health, The Hague, The Netherlands
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Kunz LI, Postma DS, Klooster K, Lapperre TS, Vonk JM, Sont JK, Kerstjens HA, Snoeck-Stroband JB, Hiemstra PS, Sterk PJ. Relapse in FEV 1 Decline After Steroid Withdrawal in COPD. Chest 2015; 148:389-396. [DOI: 10.1378/chest.14-3091] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Vooijs M, Alpay LL, Snoeck-Stroband JB, Beerthuizen T, Siemonsma PC, Abbink JJ, Sont JK, Rövekamp TA. Validity and usability of low-cost accelerometers for internet-based self-monitoring of physical activity in patients with chronic obstructive pulmonary disease. Interact J Med Res 2014; 3:e14. [PMID: 25347989 PMCID: PMC4259960 DOI: 10.2196/ijmr.3056] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 03/22/2014] [Accepted: 08/04/2014] [Indexed: 11/13/2022] Open
Abstract
Background The importance of regular physical activity for patients with chronic obstructive pulmonary disease (COPD) is well-established. However, many patients do not meet the recommended daily amount. Accelerometers might provide patients with the information needed to increase physical activity in daily life. Objective Our objective was to assess the validity and usability of low-cost Internet-connected accelerometers. Furthermore we explored patients’ preferences with regards to the presentation of and feedback on monitored physical activity. Methods To assess concurrent validity we conducted a field validation study with patients who wore two low-cost accelerometers, Fitbit and Physical Activity Monitor (PAM), at the same time along with a sophisticated multisensor accelerometer (SenseWear Armband) for 48 hours. Data on energy expenditure assessed from registrations from the two low-cost accelerometers were compared to the well validated SenseWear Armband which served as a reference criterion. Usability was examined in a cross-over study with patients who, in succession, wore the Fitbit and the PAM for 7 consecutive days and filled out a 16 item questionnaire with regards to the use of the corresponding device Results The agreement between energy expenditure (METs) from the SenseWear Armband with METs estimated by the Fitbit and PAM was good (r=.77) and moderate (r=.41), respectively. The regression model that was developed for the Fitbit explained 92% whereas the PAM-model could explain 89% of total variance in METs measured by the SenseWear. With regards to the usability, both the Fitbit and PAM were well rated on all items. There were no significant differences between the two devices. Conclusions The low-cost Fitbit and PAM are valid and usable devices to measure physical activity in patients with COPD. These devices may be useful in long-term interventions aiming at increasing physical activity levels in these patients.
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Affiliation(s)
- Martijn Vooijs
- Rijnlands Rehabilitation Center, Department of Cardiac and Pulmonary Rehabilitation, Leiden, Netherlands.
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Kruis AL, Boland MRS, Assendelft WJJ, Gussekloo J, Tsiachristas A, Stijnen T, Blom C, Sont JK, Rutten-van Mölken MPHM, Chavannes NH. Effectiveness of integrated disease management for primary care chronic obstructive pulmonary disease patients: results of cluster randomised trial. BMJ 2014; 349:g5392. [PMID: 25209620 PMCID: PMC4160285 DOI: 10.1136/bmj.g5392] [Citation(s) in RCA: 95] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate the long term effectiveness of integrated disease management delivered in primary care on quality of life in patients with chronic obstructive pulmonary disease (COPD) compared with usual care. DESIGN 24 month, multicentre, pragmatic cluster randomised controlled trial SETTING 40 general practices in the western part of the Netherlands PARTICIPANTS Patients with COPD according to GOLD (Global Initiative for COPD) criteria. Exclusion criteria were terminal illness, cognitive impairment, alcohol or drug misuse, and inability to fill in Dutch questionnaires. Practices were included if they were willing to create a multidisciplinary COPD team. INTERVENTION General practitioners, practice nurses, and specialised physiotherapists in the intervention group received a two day training course on incorporating integrated disease management in practice, including early recognition of exacerbations and self management, smoking cessation, physiotherapeutic reactivation, optimal diagnosis, and drug adherence. Additionally, the course served as a network platform and collaborating healthcare providers designed an individual practice plan to integrate integrated disease management into daily practice. The control group continued usual care (based on international guidelines). MAIN OUTCOME MEASURES The primary outcome was difference in health status at 12 months, measured by the Clinical COPD Questionnaire (CCQ); quality of life, Medical Research Council dyspnoea, exacerbation related outcomes, self management, physical activity, and level of integrated care (PACIC) were also assessed as secondary outcomes. RESULTS Of a total of 1086 patients from 40 clusters, 20 practices (554 patients) were randomly assigned to the intervention group and 20 clusters (532 patients) to the usual care group. No difference was seen between groups in the CCQ at 12 months (mean difference -0.01, 95% confidence interval -0.10 to 0.08; P=0.8). After 12 months, no differences were seen in secondary outcomes between groups, except for the PACIC domain "follow-up/coordination" (indicating improved integration of care) and proportion of physically active patients. Exacerbation rates as well as number of days in hospital did not differ between groups. After 24 months, no differences were seen in outcomes, except for the PACIC follow-up/coordination domain. CONCLUSION In this pragmatic study, an integrated disease management approach delivered in primary care showed no additional benefit compared with usual care, except improved level of integrated care and a self reported higher degree of daily activities. The contradictory findings to earlier positive studies could be explained by differences between interventions (provider versus patient targeted), selective reporting of positive trials, or little room for improvement in the already well developed Dutch healthcare system. TRIAL REGISTRATION Netherlands Trial Register NTR2268.
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Affiliation(s)
- Annemarije L Kruis
- Department of Public Health and Primary Care, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, Netherlands
| | - Melinde R S Boland
- Institute for Medical Technology Assessment, Erasmus University, 3000 DR Rotterdam, Netherlands
| | - Willem J J Assendelft
- Department of Public Health and Primary Care, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, Netherlands Department of Primary and Community Care, Radboud University Nijmegen Medical Centre, 6500 HB Nijmegen, Netherlands
| | - Jacobijn Gussekloo
- Department of Public Health and Primary Care, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, Netherlands
| | - Apostolos Tsiachristas
- Institute for Medical Technology Assessment, Erasmus University, 3000 DR Rotterdam, Netherlands
| | - Theo Stijnen
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre
| | - Coert Blom
- Stichting Zorgdraad Foundation, 6862 XN Oosterbeek, Netherlands
| | - Jacob K Sont
- Department of Medical Decision Making, Leiden University Medical Centre
| | | | - Niels H Chavannes
- Department of Public Health and Primary Care, Leiden University Medical Centre, PO Box 9600, 2300 RC Leiden, Netherlands
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Honkoop PJ, Loijmans RJB, Termeer EH, Snoeck-Stroband JB, van den Hout WB, Bakker MJ, Assendelft WJJ, ter Riet G, Sterk PJ, Schermer TRJ, Sont JK. Symptom- and fraction of exhaled nitric oxide-driven strategies for asthma control: A cluster-randomized trial in primary care. J Allergy Clin Immunol 2014; 135:682-8.e11. [PMID: 25174865 DOI: 10.1016/j.jaci.2014.07.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 06/04/2014] [Accepted: 07/15/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aiming at partly controlled asthma (PCa) instead of controlled asthma (Ca) might decrease asthma medication use. Biomarkers, such as the fraction of exhaled nitric oxide (Feno), allow further tailoring of treatment. OBJECTIVE We sought to assess the cost-effectiveness and clinical effectiveness of pursuing PCa, Ca, or Feno-driven controlled asthma (FCa). METHODS In a nonblind, pragmatic, cluster-randomized trial in primary care, adults (18-50 years of age) with a doctor's diagnosis of asthma who were prescribed inhaled corticosteroids were allocated to one of 3 treatment strategies: (1) aiming at PCa (Asthma Control Questionnaire [ACQ] score <1.50); (2) aiming at Ca (ACQ score <0.75); and (3) aiming at FCa (ACQ score <0.75 and Feno value <25 ppb). During 12 months' follow-up, treatment was adjusted every 3 months by using an online decision support tool. Outcomes were incremental cost per quality-adjusted life year gained, asthma control (ACQ score), quality of life (Asthma Quality of Life Questionnaire score), asthma medication use, and severe exacerbation rate. RESULTS Six hundred eleven participants were allocated to the PCa (n = 219), Ca (n = 203), or FCa (n = 189) strategies. The FCa strategy improved asthma control compared with the PCa strategy (P < .02). There were no differences in quality of life (P ≥ .36). Asthma medication use was significantly lower for the PCa and FCa strategies compared with the Ca strategy (medication costs: PCa, $452; Ca, $551; and FCa, $456; P ≤ .04). The FCa strategy had the highest probability of cost-effectiveness at a willingness to pay of $50,000/quality-adjusted life year (86%; PCa, 2%; Ca, 12%). There were no differences in severe exacerbation rate. CONCLUSION A symptom- plus Feno-driven strategy reduces asthma medication use while sustaining asthma control and quality of life and is the preferred strategy for adult asthmatic patients in primary care.
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Affiliation(s)
- Persijn J Honkoop
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
| | - Rik J B Loijmans
- Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands
| | - Evelien H Termeer
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jiska B Snoeck-Stroband
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Moira J Bakker
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem J J Assendelft
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands; Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gerben ter Riet
- Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands
| | - Peter J Sterk
- Department of Pulmonology, Academic Medical Center, Amsterdam, The Netherlands
| | - Tjard R J Schermer
- Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jacob K Sont
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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de Weger LA, Beerthuizen T, Hiemstra PS, Sont JK. Development and validation of a 5-day-ahead hay fever forecast for patients with grass-pollen-induced allergic rhinitis. Int J Biometeorol 2014; 58:1047-1055. [PMID: 23780494 DOI: 10.1007/s00484-013-0692-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 05/15/2013] [Accepted: 05/30/2013] [Indexed: 06/02/2023]
Abstract
One-third of the Dutch population suffers from allergic rhinitis, including hay fever. In this study, a 5-day-ahead hay fever forecast was developed and validated for grass pollen allergic patients in the Netherlands. Using multiple regression analysis, a two-step pollen and hay fever symptom prediction model was developed using actual and forecasted weather parameters, grass pollen data and patient symptom diaries. Therefore, 80 patients with a grass pollen allergy rated the severity of their hay fever symptoms during the grass pollen season in 2007 and 2008. First, a grass pollen forecast model was developed using the following predictors: (1) daily means of grass pollen counts of the previous 10 years; (2) grass pollen counts of the previous 2-week period of the current year; and (3) maximum, minimum and mean temperature (R (2)=0.76). The second modeling step concerned the forecasting of hay fever symptom severity and included the following predictors: (1) forecasted grass pollen counts; (2) day number of the year; (3) moving average of the grass pollen counts of the previous 2 week-periods; and (4) maximum and mean temperatures (R (2)=0.81). Since the daily hay fever forecast is reported in three categories (low-, medium- and high symptom risk), we assessed the agreement between the observed and the 1- to 5-day-ahead predicted risk categories by kappa, which ranged from 65 % to 77 %. These results indicate that a model based on forecasted temperature and grass pollen counts performs well in predicting symptoms of hay fever up to 5 days ahead.
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Affiliation(s)
- Letty A de Weger
- Department of Pulmonology, Leiden University Medical Center, PO Box 9600, Albinusdreef 2, 2300RC, Leiden, The Netherlands,
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van Laar JM, Farge D, Sont JK, Naraghi K, Marjanovic Z, Larghero J, Schuerwegh AJ, Marijt EWA, Vonk MC, Schattenberg AV, Matucci-Cerinic M, Voskuyl AE, van de Loosdrecht AA, Daikeler T, Kötter I, Schmalzing M, Martin T, Lioure B, Weiner SM, Kreuter A, Deligny C, Durand JM, Emery P, Machold KP, Sarrot-Reynauld F, Warnatz K, Adoue DFP, Constans J, Tony HP, Del Papa N, Fassas A, Himsel A, Launay D, Lo Monaco A, Philippe P, Quéré I, Rich É, Westhovens R, Griffiths B, Saccardi R, van den Hoogen FH, Fibbe WE, Socié G, Gratwohl A, Tyndall A. Autologous hematopoietic stem cell transplantation vs intravenous pulse cyclophosphamide in diffuse cutaneous systemic sclerosis: a randomized clinical trial. JAMA 2014; 311:2490-8. [PMID: 25058083 DOI: 10.1001/jama.2014.6368] [Citation(s) in RCA: 454] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE High-dose immunosuppressive therapy and autologous hematopoietic stem cell transplantation (HSCT) have shown efficacy in systemic sclerosis in phase 1 and small phase 2 trials. OBJECTIVE To compare efficacy and safety of HSCT vs 12 successive monthly intravenous pulses of cyclophosphamide. DESIGN, SETTING, AND PARTICIPANTS The Autologous Stem Cell Transplantation International Scleroderma (ASTIS) trial, a phase 3, multicenter, randomized (1:1), open-label, parallel-group, clinical trial conducted in 10 countries at 29 centers with access to a European Group for Blood and Marrow Transplantation-registered transplant facility. From March 2001 to October 2009, 156 patients with early diffuse cutaneous systemic sclerosis were recruited and followed up until October 31, 2013. INTERVENTIONS HSCT vs intravenous pulse cyclophosphamide. MAIN OUTCOMES AND MEASURES The primary end point was event-free survival, defined as time from randomization until the occurrence of death or persistent major organ failure. RESULTS A total of 156 patients were randomly assigned to receive HSCT (n = 79) or cyclophosphamide (n = 77). During a median follow-up of 5.8 years, 53 events occurred: 22 in the HSCT group (19 deaths and 3 irreversible organ failures) and 31 in the control group (23 deaths and 8 irreversible organ failures). During the first year, there were more events in the HSCT group (13 events [16.5%], including 8 treatment-related deaths) than in the control group (8 events [10.4%], with no treatment-related deaths). At 2 years, 14 events (17.7%) had occurred cumulatively in the HSCT group vs 14 events (18.2%) in the control group; at 4 years, 15 events (19%) had occurred cumulatively in the HSCT group vs 20 events (26%) in the control group. Time-varying hazard ratios (modeled with treatment × time interaction) for event-free survival were 0.35 (95% CI, 0.16-0.74) at 2 years and 0.34 (95% CI, 0.16-0.74) at 4 years. CONCLUSIONS AND RELEVANCE Among patients with early diffuse cutaneous systemic sclerosis, HSCT was associated with increased treatment-related mortality in the first year after treatment. However, HCST conferred a significant long-term event-free survival benefit. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN54371254.
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Affiliation(s)
- Jacob M van Laar
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Dominique Farge
- Internal Medicine and Vascular Disease Unit, AP-HP Hôpital Saint-Louis, Paris 7 University, France
| | - Jacob K Sont
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - Kamran Naraghi
- Department of Rheumatology, The James Cook University Hospital, Middlesbrough, United Kingdom
| | - Zora Marjanovic
- Service d'Hématologie Clinique et de Thérapie Cellulaire, AP-HP Hôpital Saint-Antoine, Paris 6 University, Paris, France
| | - Jérôme Larghero
- Clinical Investigation Center in Biotherapies and Cell Therapy Unit, AP-HP Hôpital Saint-Louis, Paris 7 University, France
| | - Annemie J Schuerwegh
- Department of Rheumatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Erik W A Marijt
- Department of Hematology, Leiden University Medical Center, Leiden, the Netherlands
| | - Madelon C Vonk
- Department of Rheumatology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Anton V Schattenberg
- Department of Hematology, Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands
| | - Marco Matucci-Cerinic
- Department of Biomedicine, Division of Rheumatology AOUC and Department of Experimental and Clinical Medicine, University of Florence, Florence
| | - Alexandre E Voskuyl
- Department of Rheumatology, VU University Medical Center, Amsterdam, the Netherlands
| | | | - Thomas Daikeler
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - Ina Kötter
- Department of Internal Medicine II, University Hospital, Tübingen, Germany
| | - Marc Schmalzing
- Department of Internal Medicine II, University Hospital, Tübingen, Germany
| | - Thierry Martin
- Department of Clinical Immunology, Strasbourg University Hospital, Strasbourg, France
| | - Bruno Lioure
- Service d'Hématologie et d'Oncologie, Unité de Greffe de Cellules Souches Hématopoïétiques, Centre Hospitalier Universitaire Hautepierre, Strasbourg, France
| | - Stefan M Weiner
- 2.Medizinische Abteilung Krankenhaus der Barmherzigen Brüder Trier, Trier, Germany
| | - Alexander Kreuter
- Department of Dermatology, Venereology, and Allergology, HELIOS St. Elisabeth Hospital Oberhausen, Oberhausen,Germany
| | - Christophe Deligny
- Service Médecine Interne, Hôpital Pierre Zobda Quitman, Fort-de France, Martinique
| | - Jean-Marc Durand
- Department of Internal Medicine CHU La Conception, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Klaus P Machold
- Klinische Abteilung für Rheumatologie, Medizinische Universität, Vienna, Austria
| | | | - Klaus Warnatz
- Division of Rheumatology and Clinical Immunology, University Medical Center Freiburg, Freiburg, Germany
| | - Daniel F P Adoue
- Service Médecine Interne, Centre Hospitalier Universitaire Toulouse
| | - Joël Constans
- Service Médecine Interne et Médecine Vasculaire, Hôpital St-André, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France
| | - Hans-Peter Tony
- Department of Rheumatology and Clinical Immunology, University of Würzburg Medical Center, Würzburg, Germany
| | | | - Athanasios Fassas
- Department of Hematology, Cell and Gene Therapy Center, George Papanicolaou Hospital, Thessaloniki, Greece
| | - Andrea Himsel
- Department of Rheumatology, University Hospital Frankfurt, Frankfurt, Germany
| | - David Launay
- Service de Médecine Interne, Hôpital Claude-Huriez, Lille, France
| | - Andrea Lo Monaco
- Section and Unit of Rheumatology, Department of Medical Sciences, University of Ferrara, Italy
| | - Pierre Philippe
- Service de Médecine Interne, Centre Hospitalier Universitaire Estaing, Clermont-Ferrand, France
| | - Isabelle Quéré
- Department of Internal Medicine, Montpellier University Hospital, Montpellier, France
| | - Éric Rich
- Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Rene Westhovens
- Skeletal Biology and Engineering Research Center, Department of Development and Regeneration KU Leuven, Rheumatology, University Hospitals, Leuven, Belgium
| | - Bridget Griffiths
- Department of Rheumatology, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Riccardo Saccardi
- Department of Hematology, Careggi University Hospital, Florence, Italy
| | | | - Willem E Fibbe
- Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, the Netherlands
| | - Gérard Socié
- Hematology/Transplantation, AP-HP Hôpital Saint-Louis, Paris 7 University, France
| | - Alois Gratwohl
- Department of Hematology, University Hospital Basel, Basel, Switzerland
| | - Alan Tyndall
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
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Honkoop PJ, Loijmans RJB, Termeer EH, Snoeck-Stroband JB, Ter Riet G, Schermer TRJ, Sont JK. Comparison between an online self-administered and an interviewer-administered version of the Asthma Control Questionnaire: a cross-sectional validation study. Prim Care Respir J 2014; 22:284-9. [PMID: 23616053 PMCID: PMC6442815 DOI: 10.4104/pcrj.2013.00041] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background: Online self-management programmes for asthma have recently become available. International guidelines suggest that the Asthma Control Questionnaire (ACQ) can be used in these programmes. In order to assess the current level of control and guide therapy, the same cut-off values are being used as in conventional asthma management. However, results might differ between different types of administration of the ACQ. Aims: To assess the agreement between an online self-administered version of the ACQ and an interviewer-administered version at a routine visit. Methods: Cross-sectional data from primary care asthma patients in the Asthma Control Cost Utility Randomized Trial Evaluation (ACCURATE) trial aged 18–50 years and prescribed inhaled steroids were analysed. We selected patients who self-administered an ACQ online and subsequently had an ACQ completed by a nurse practitioner within 7 days at a trial-related control visit. ACQ scores were calculated and agreement assessed by paired t-tests, Pearson's correlation coefficient and a Bland-Altman plot. Results: A total of 351 patients were eligible (68% female, mean age 40 years). The time interval between the two versions was 3.2 days. There was a significant difference of 0.14 (95% CI 0.09 to 0.20; p<0.001) between the results of the online self-administered ACQ (mean 1.04±0.04) and the interviewer-administered ACQ results (0.90±0.04). The Pearson correlation coefficient was 0.79. The limits of agreement (−0.86, 1.14) exceeded the predefined minimal clinically important difference between results (±0.5). The Bland-Altman plot therefore showed insufficient agreement. Conclusions: Assessment of asthma control by the ACQ is influenced by the type of administration. Our results suggest that better control of asthma is perceived when interacting with a caregiver than by online self-assessment.
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Affiliation(s)
- Persijn J Honkoop
- Department of Medical Decision Making, Leiden University Medical Center, The Netherlands • Department of Public Health and Primary Care, Leiden University Medical Center, the Netherlands
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van Gaalen JL, Beerthuizen T, van der Meer V, van Reisen P, Redelijkheid GW, Snoeck-Stroband JB, Sont JK. Long-term outcomes of internet-based self-management support in adults with asthma: randomized controlled trial. J Med Internet Res 2013; 15:e188. [PMID: 24028826 PMCID: PMC3785973 DOI: 10.2196/jmir.2640] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 05/21/2013] [Accepted: 06/11/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Long-term asthma management falls short of the goals set by international guidelines. The Internet is proposed as an attractive medium to support guided self-management in asthma. Recently, in a multicenter, pragmatic randomized controlled parallel trial with a follow-up period of 1 year, patients were allocated Internet-based self-management (IBSM) support (Internet group [IG]) or usual care (UC) alone. IBSM support was automatically terminated after 12 months of follow-up. In this study, IBSM support has been demonstrated to improve asthma-related quality of life, asthma control, lung function, and the number of symptom-free days as compared to UC. IBSM support was based on known key components for effective self-management and included weekly asthma control monitoring and treatment advice, online and group education, and communication (both online and offline) with a respiratory nurse. OBJECTIVE The objective of the study was to assess the long-term effects of providing patients 1 year of IBSM support as compared to UC alone. METHODS Two hundred adults with physician-diagnosed asthma (3 or more months of inhaled corticosteroids prescribed in the past year) from 37 general practices and 1 academic outpatient department who previously participated were invited by letter for additional follow-up at 1.5 years after finishing the study. The Asthma Control Questionnaire (ACQ) and the Asthma Quality of Life Questionnaire (AQLQ) were completed by 107 participants (60 UC participants and 47 IG participants). A minimal clinical important difference in both questionnaires is 0.5 on a 7-point scale. RESULTS At 30 months after baseline, a sustained and significant difference in terms of asthma-related quality of life of 0.29 (95% CI 0.01-0.57) and asthma control of -0.33 (95% CI -0.61 to -0.05) was found in favor of the IBSM group. No such differences were found for inhaled corticosteroid dosage or for lung function, measured as forced expiratory volume in 1 second. CONCLUSIONS Improvements in asthma-related quality of life and asthma control were sustained in patients who received IBSM support for 1 year, even up to 1.5 years after terminating support. Future research should be focused on implementation of IBSM on a wider scale within routine asthma care. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number (ISRCTN): 79864465; http://www.controlled-trials.com/ISRCTN79864465 (Archived by WebCite at http://www.webcitation.org/6J4VHhPk4).
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Affiliation(s)
- Johanna L van Gaalen
- Leiden University Medical Center, Department of Medical Decision Making, Leiden, Netherlands
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Honkoop PJ, Sont JK. The number needed to treat provides additional insight on the performance of detection points of asthma exacerbations in self-management plans. Thorax 2013; 68:1069-70. [PMID: 23821391 DOI: 10.1136/thoraxjnl-2013-203853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Persijn J Honkoop
- Department of Medical Decision Making, Leiden University Medical Center, , Leiden, Zuid Holland, The Netherlands
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Sterk PJ, Sont JK. Strategies for tailoring asthma treatment in adults. JAMA 2013; 309:135-6. [PMID: 23299596 DOI: 10.1001/jama.2012.73379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Rikkers-Mutsaerts ERVM, Winters AE, Bakker MJ, van Stel HF, van der Meer V, de Jongste JC, Sont JK. Internet-based self-management compared with usual care in adolescents with asthma: a randomized controlled trial. Pediatr Pulmonol 2012; 47:1170-9. [PMID: 22644646 DOI: 10.1002/ppul.22575] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 03/12/2012] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Asthma control often is poor in adolescents and this causes considerable morbidity. Internet-based self-management (IBSM) improves asthma-related quality of life in adults. We hypothesized that IBSM improves asthma-related quality of life in adolescents. METHODS Adolescents (12-18 years) with persistent and not well-controlled asthma participated in a randomized controlled trial with 1 year follow-up and were allocated to IBSM (n = 46) or usual care (UC, n = 44). IBSM consisted of weekly asthma control monitoring with treatment advice by a web-based algorithm. Outcomes included asthma-related quality of life (Pediatric Asthma Quality of Life Questionnaire, PAQLQ) and asthma control (Asthma Control Questionnaire, ACQ) and were analyzed by a linear mixed-effects model. RESULTS At 3 months, PAQLQ improved with 0.40 points (95% CI: 0.17-0.62, P < 0.01), by IBSM compared to 0.0 points for UC (P = 0.02 for the difference). At 12 months the between-group difference was -0.05 (95% CI: -0.50 to 0.41, P = 0.85). At 3 months ACQ improved more in IBSM than in UC (difference: -0.32 points; 95% CI: -0.56 to -0.079, P < 0.01). At 12 months the difference was -0.05 (95% CI: -0.35 to 0.25, P = 0.75). CONCLUSION IBSM improved asthma-related quality of life and asthma control in adolescents with not well-controlled asthma after 3 months, but not after 12 months.
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van Gaalen JL, Bakker MJ, van Bodegom-Vos L, Snoeck-Stroband JB, Assendelft WJJ, Kaptein AA, van der Meer V, Taube C, Thoonen BP, Sont JK. Implementation strategies of internet-based asthma self-management support in usual care. Study protocol for the IMPASSE cluster randomized trial. Implement Sci 2012; 7:113. [PMID: 23171672 PMCID: PMC3514342 DOI: 10.1186/1748-5908-7-113] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Accepted: 11/16/2012] [Indexed: 11/10/2022] Open
Abstract
Background Internet-based self-management (IBSM) support cost-effectively improves asthma control, asthma related quality of life, number of symptom-free days, and lung function in patients with mild to moderate persistent asthma. The current challenge is to implement IBSM in clinical practice. Methods/design This study is a three-arm cluster randomized trial with a cluster pre-randomisation design and 12 months follow-up per practice comparing the following three IBSM implementation strategies: minimum strategy (MS): dissemination of the IBSM program; intermediate strategy (IS): MS + start-up support for professionals (i.e., support in selection of the appropriate population and training of professionals); and extended strategy (ES): IS + additional training and ongoing support for professionals. Because the implementation strategies (interventions) are primarily targeted at general practices, randomisation will occur at practice level. In this study, we aim to evaluate 14 primary care practices per strategy in the Leiden-The Hague region, involving 140 patients per arm. Patients aged 18 to 50 years, with a physician diagnosis of asthma, prescription of inhaled corticosteroids, and/or montelukast for ≥3 months in the previous year are eligible to participate. Primary outcome measures are the proportion of referred patients that participate in IBSM, and the proportion of patients that have clinically relevant improvement in the asthma-related quality of life. The secondary effect measures are clinical outcomes (asthma control, lung function, usage of airway treatment, and presence of exacerbations); self-management related outcomes (health education impact, medication adherence, and illness perceptions); and patient utilities. Process measures are the proportion of practices that participate in IBSM and adherence of professionals to implementation strategies. Cost-effective measurements are medical costs and healthcare consumption. Follow-up is six months per patient. Discussion This study provides insight in the amount of support that is required by general practices for cost-effective implementation of IBSM. Additionally, design and results can be beneficial for implementation of other self-management initiatives in clinical practice. Trial registration the Netherlands National Trial Register NTR2970
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Affiliation(s)
- Johanna L van Gaalen
- Department of Medical Decision Making, Leiden University Medical Centre, P,O, Box 9600, 2300, RC, Leiden, the Netherlands.
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