Portugal at the cross road of international chronic respiratory programmes

July 1–4, 2015 two meetings will be held with the Directorate General of Health in Lisbon, Portugal to discuss chronic respiratory programmes of the WHO Global Alliance against Chronic Respiratory Diseases (GARD)1, 2 and European Innovation Partnership on Active and Healthy Ageing (EIP on AHA)3 (AIRWAYS ICPs: Integrated Care Pathways for airway diseases).4 The goals of these meetings will be to make an update of these two international actions and to strengthen the WHO noncommunicable disease (NCD) action plan (2013–2020).

Chronic respiratory diseases (CRD) include asthma, rhinitis and COPD, occupational lung diseases, sleep apnoea syndrome and genetic syndromes such as cystic fibrosis.1, 2 Over 1 billion people in the world suffer from CRDs. They represent one of the priorities of the EU (3053rd and 3131st Conclusions of the EU Council, 2010 and 2011)5, 6 and the United Nations (High Level meeting on Non-Communicable Diseases, 2011).7 The 2011 Polish Presidence of the EU Council made the prevention, early diagnosis and treatment of asthma and allergic diseases a priority for the EU's public health policy in order to reduce health inequalities.5 The early determinants of CRDs were reinforced during the Cyprus Presidency of the EU Council.8 The 2014 Italian Presidence of the EU Council has prioritized CRDs. CRDs represent a model of chronic diseases due to their prevalence, burden (3 million annual deaths due to COPD), and comorbidities with other chronic diseases.9

European Innovation Partnerships (EIP) attempt to enhance EU competitiveness and tackle societal challenges by fostering innovation. Active and Healthy Ageing (AHA) is a major societal challenge common to all countries and to all populations.10 Ageing, intertwined with socioeconomic inequalities, is an under-appreciated cause of poverty. AHA needs to be promoted very early in life to be successful. The EIP on AHA is deployed in 3 areas and 6 action plans.11

AIRWAYS ICPs (integrated care pathways for airway diseases) has been selected as the model of NCDs for Area 5 of the B3 Action Plan of the EIP on AHA (DG Sanco and DG CNECT).4 It was launched by NHS England (Newcastle, February 2014) and has been endorsed by the EIP on AHA Reference Site Network. The goals of AIRWAYS ICPs include the launch of a collaboration to develop multisectoral CRD care pathways (ICPs) in European countries and regions, as part of the EIP on AHA (Area 5 of the Action Plan B3 of EIP on AHA, DG Sanco, DG CNECT) as well as a global scale up with WHO GARD (GARD demonstration research project).1, 2 AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and the WHO NCD Action Plan (2013–2020). The goals of AIRWAYS ICPs are listed in Table 1.

Table 1. Goals of AIRWAYS ICPs.

1. Proposing a common framework of care pathways for chronic respiratory diseases which will facilitate comparability and trans-national initiatives
2. Proposing plans targeted to all populations according to culture, health systems and income
3. Developing a strategy based on WHO PEN and the essential list of drugs for low and middle income countries
4. Informing cost-effective policy development, in particular strengthening those on smoking and environment exposure
5. Aiding risk stratification in chronic disease patients with a common strategy
6. Building a sentinel network for allergic diseases and asthma
7. Having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and the long-term (healthy ageing)
8. Tackling chronic diseases across the life cycle
9. Defining active and healthy ageing
10. And ultimately reducing the healthcare burden (emergency visits, avoidable hospitalizations, disability and costs) while improving quality of life and promoting active and healthy ageing. In the longer term, the incidence of disease may be reduced by innovative prevention strategies

Portugal has been promoting CRDs for over 10 years by the scientific Societies and, more recently, through the National Program on Respiratory Diseases, from the Directorate-General for Health.

The first meeting will review the different actions of AIRWAYS ICPs and launch some activities which are finalized. Among them, a repository for good practices, the new ARIA 2015 guidelines, the MACVIA-ARIA sentinel network and the scaling up strategy.

Allergic rhinitis is one of the most prevalent diseases in the world (25% of the EU population). Although symptoms of rhinitis appear to be trivial, the disease affects social activities, school and work performance and allergic rhinitis is associated with a detrimental effect on examination performance.12 It is often associated with or precedes asthma. Allergic rhinitis has been considered to alter AHA if not appropriately managed.5, 6 ARIA, a guideline for allergic rhinitis and its comorbidity with asthma, was the first comorbidity guideline in chronic diseases. It was developed in the late 1999s in collaboration with WHO using the recommended methodology for guidelines (Shekelle).13 It was updated in 2008.14 It has been revised using the GRADE methodology (2010).15, 16, 17 It is the most widely used guideline for rhinitis, and rhinitis and asthma comorbidity globally.18 ARIA is implemented in 64 countries and the pocket guide of the guideline has been translated into 52 languages. However, there is a need to develop a new set of recommendations which will be integrated care pathways. The ARIA 2015 will be launched during the meeting in Lisbon.

The MACVIA-ARIA Sentinel Network (MASK) proposes to study the symptoms of patients suffering from allergic symptoms during the pollen season in order to make them sentinels for the onset and severity of the pollen season. Patients are geolocalised and will evaluate their symptoms by visual analogue scale (VAS) using a cell phone with a touch screen or internet. This information will be coded and sent to a central database and subsequently to all patients registered in the system. A Clinical Decision Support System (CDSS)19, 20 will immediately propose advice for (standardized) pharmacologic treatment. Patients with uncontrolled disease (SCUAD)21 will be easily defined as those resistant to treatment despite optimal treatment. Moreover, conjunctival symptoms and asthma will be monitored by the system. It will be combined with CARAT (Control of Allergic Rhinitis and Asthma Test)22, 23 in order to better phenotype the patients, and an e-learning tool.

The EIP on AHA has proposed a 5-step framework for developing an individual scaling up strategy: (1) what to scale up: (1–1) databases of good practices, (1–2) assessment of viability of the scaling up of good practices, (1–3) classification of good practices for local replication and (2) how to scale up: (2–1) facilitating partnerships for scaling up, (2–2) implementation of key success factors and lessons learnt. This strategy has already been applied to the CRD action plan of the EIP on AHA.

This meeting will have the support of the Région Languedoc Roussillon24 and the Coimbra Region, and will be the third meeting of the Collaborative Network of EIP on AHA Reference Sites.

The second meeting will be the GARD annual meeting and will review advances of this WHO alliance.

Both meetings are supported by the Portuguese Respiratory Society and show the implication of this society in international actions on CRDs.

Corresponding author. carlos.crobalo@gmail.com

Bibliography
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