In addition, assessment of difficult-to-manage asthma in primary care might be hampered by a lack of knowledge about all potentially preventable or treatable factors. Within this definition, a systematic approach to reviewing all potentially preventable and treatable factors before stepping up treatment and/or deciding asthma is severe is not explicitly specified, though guidelines do advocate reviewing preventable factors.
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12, 13 International guidelines define severe asthma as asthma that requires treatment with high-dose inhaled corticosteroids plus a second controller and/or systemic corticosteroids to prevent it from becoming ‘uncontrolled’, or that remains ‘uncontrolled’ despite this therapy, when supervised by a specialised multidisciplinary team for at least 3 months. 11 By doing so, the potentially life-saving but thus far very costly new types of treatment can be reserved for the patients with truly severe asthma. 9 It requires identification and management of treatable traits, 10 predominantly beyond pharmacotherapy. 8 Difficult-to-manage asthma is asthma that either the person affected or the clinician finds difficult to manage, which may or may not be driven by the severity of the disease. 7 Therefore, it is of vital importance to differentiate between patients with truly severe asthma (estimated as 3.6% of people with asthma in the Netherlands) from persons with difficult-to-manage asthma (estimated as 17.4% of people with asthma). 6 Recently, major preventable factors were found in 67% of asthma deaths, and only a small portion of patients had such severe asthma that mortality could not have been prevented. Mortality remains high despite the availability of effective therapies. 1– 3 Even now, 60% of the asthmatics are poorly controlled, which is related to a significant reduction in quality of life. Other countries could use a similar approach to create a locally adapted version of such a programme.Īsthma is a common respiratory condition, accounting for serious morbidity for patients and an important negative impact on society and economy owing to high costs of medication, hospitalisation and loss of productivity. This should facilitate implementation of this programme within the existing structure of educational material on asthma and chronic obstructive pulmonary disease (COPD) in primary care, with potential for improving management of difficult-to-manage asthma. Finally, we created the alphabet acronym for the categories ‘the A–I of difficult-to-manage asthma’ to resonate with an established Dutch ‘A–E acronym for determining asthma control’. In the third round, the selected items were categorised and items were ranked within the categories according to relevance. In the second round, we asked participants to rate the relevance of specific items on a seven-point Likert scale, and 46 items were selected as relevant.
In the first round, the participants were asked to provide potentially relevant items for a difficult-to-manage asthma programme, which resulted in 67 items. We used a modified three-round e-Delphi approach to assess the opinion of all relevant stakeholders (general practitioners, pulmonologists, practice nurses, pulmonary nurses and people with asthma). Local adaptation of this approach, however, is required to ensure an appropriate strategy for implementation in the Dutch context. The International Primary Care Respiratory Group approach emphasises the importance of differentiating patients with asthma that is difficult to manage from those with severe disease. Notes doesn't have scripting commands for the selection per se, but the show command will select the specified note in the process of showing it.Patients with difficult-to-manage asthma represent a heterogeneous subgroup of asthma patients who require extensive assessment and tailored management.
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