In this Issue October 2006

Allergic Rhinitis and the Patient with Asthma

IPCRG 3rd World Conference Report

Developments in primary care in the UK

Monitoring symptoms or peak flow?

Research Funding Opportunities 

Conference Diary 2006

Allergic Rhinitis and the Patient with Asthma

The National Asthma Council Australia and the Australasian Society of Clinical Immunology and Allergy have launched a new set of resources focussing on the management of allergic rhinitis in people with asthma.

According to Associate Professor Mimi Tang, chairperson of the expert working group responsible for writing the new resources, the prevalence of allergic rhinitis is increasing.

The condition now affects approximately 16 per cent of Australians, including almost eight per cent of children and adolescents.

“Rhinitis occurs in an estimated 75-80 per cent of patients with asthma,” Assoc Prof Tang explained. “And, recent studies suggest that allergic rhinitis is a risk factor for developing asthma in people who do not yet have asthma.

“Allergic rhinitis on its own can significantly affect a person’s daily activities and impair their quality of life. When it occurs in a patient with asthma, it can contribute to airway symptoms and the control of allergic rhinitis must be considered in the management plan.”

The new eight-page health professional guide; Allergic rhinitis and the patient with asthma, provides a comprehensive, step-by-step approach to asthma management, including investigation of allergic rhinitis and effective treatment.

Issues and advice are provided in areas relating to

• allergen avoidance,

• nasal irrigation,

• pharmacological treatment and

• immunomodulatory therapy

As the areas are explored specific ‘practice points’ for consideration during patient consultations are clearly highlighted.

The companion consumer information brochure, Allergic rhinitis and your asthma – What you should know, has also been launched to support the health professionals’ guide and provide clinicians with an important tool to help explain the link between allergic rhinitis and asthma. The brochure also gives clear, concise information on how to minimise the daily impact of both conditions.

National distribution of the publications to doctors and pharmacists is underway.

Both publications are available online or can be ordered directly on 1 800 032 495.

With seasonal allergic rhinitis set to peak over the spring and summer, these timely new resources will provide health professionals with the latest evidence-based information at a critical time.

New publications

Allergic rhinitis and your asthma: What you should know

Allergic rhinitis and the patient with asthma: A guide for health professionals

Other Useful Resources

First Aid for Asthma

Asthma & Allergy

Asthma and Allergy: What you should know

Asthma and Allergy: A guide for health professionals

IPCRG 3rd World Conference Report

National Asthma Council Australia Project Manager Ms Kathy Hope attended the International Primary Care Respiratory Group (IPCRG) 3rd World Conference held in Oslo, Norway in June to report on proceedings through a special ‘highlights’ review.

The conference attracted 420 delegates from 29 countries around the world, including 12 from Australia. NAC committee members who took part included

• Dr Kerry Hancock, chair of the NAC GPs’ Asthma Group (GPAG),

• Dr H John Fardy and Prof. Nicholas Glasgow of GPAG,

• Prof. Justin Beilby (Asthma Management Handbook Guidelines Committee) and

• Dr Ron Tomlins, immediate past-chairman of the NAC.

Many of the topics were predictable for a respiratory conference – asthma diagnosis and management, COPD, smoking cessation and, especially relevant for developing countries, infectious diseases management. However, the conference adopted a novel approach to the three major plenary sessions (asthma, COPD, infectious diseases). Instead of being lengthy didactic presentations, the sessions were extremely interactive and challenging to the audience. Each plenary presented an overview of the topic followed by a pros and cons debate on a controversial diagnostic or treatment issue, with much comment, disagreement and often, hilarity as some speakers tried to defend the indefensible. Then two different case studies were presented for group discussion.

Selected excerpts from the IPCRG report are shown below and the full report is now available in PDF format.

IPCRG Olso Report 2006

Allergy and its Role in Respiratory Disease

One airway, one disease

Professor David Price from the UK spoke about rhinitis and asthma. He pointed out that both could be symptoms of the same disease: one airway, one disease. WHO and others recently described this so-called “One-Airway Concept”. Although rhinitis and asthma are both common diseases, they coexist more frequently than would be expected by chance with epidemiological data. The vast majority of asthma patients also suffer from allergic rhinitis and up to 40% of rhinitis patients also suffer from asthma.

Asthma Treatment Issues

Asthma treatment opportunities – getting it right

Dr John Haughney from the UK presented a down-to- earth, ‘get real’ session on asthma treatment opportunities as part of the Asthma symposium. He began by observing that inequalities in health care and economics mean we cannot provide ‘best practice’ care in all settings. Cost and infrastructure may not allow this, so we need to look at both the affordability of treatment and the availability of treatment. Factors influencing this are, for example, the economics and finance of healthcare, Quality of Adjusted Life Years (QALY) and reimbursement decisions, and the patient’s willingness and ability to pay. This, he emphasised, is very variable - this was echoed by one of the Australian delegates, certainly regarding the ‘willingness’ issue.

COPD Issues and Solutions

Treatment opportunities in COPD

We all know that COPD is a multifactorial disease, and many of us regard COPD as a hopeless or forgotten disease. Almost every smoker is aware of the risk of having lung cancer one day, less is aware of the risk of COPD. In the year 2000 there were 340.000 lung cancer patients in USA and 13,000,000 patients with diagnosed COPD, Professor Jim Reid from New Zealand told the audience. These facts should be an enormous challenge to us all. BTS guidelines set out five goals for COPD management: early and accurate diagnosis, best control of symptoms, prevention of deterioration, prevention of complications and improved quality of life. The opportunity for treatment depends on early diagnosis, dealing with causative factors and initiating appropriate treatment for the stage of the disease process.

Tools and Testing

Siren Nicolaisen and Elise Austegard, both from Norway, presented an overview of lung function testing. It is important not to do a spirometry test shortly after smoking, eating a big meal, drinking alcohol or after major exertion. Curves will not be representative and reproducible and therefore not reliable. To get the best results it is recommended to do three curves, which should look more or less the same. Flow volume loop, forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and their ratio are the most measured values; others suggested carefully that forced expiratory volume in six seconds (FEV6 )would probably be a more representative value in weaker and/or dyspnoeic patients. Spirometry needs training and training maintenance: two times four hours (a year) results in 84% acceptable curves.

Infectious Diseases: Issues of Care Worldwide

Infectious diseases and vaccination

Dr Morten Lindbaek from Norway, Professor Justin Beilby from Australia, and Dr Alan Kaplan from Canada presented the infectious diseases symposium on URTIs, bronchitis and pneumonia, and vaccination. Regarding URTIs, there are controversies over the treatment of tonsillitis, otitis media, and sinusitis. The “ear-prone child” (a Nordic concept) is defined by having 3 episodes of OM in the last half-year, or 4 episodes in one year. Apparently, 4% of all children have an inherited disposition to atopy, and passive smoking may also be a factor in children who develop OM, which is especially prevalent in boys and develops at a young age. Public education on this is essential to influence parents’ views. Audience members from different countries gave examples of current practice.

Experiences from Downunder

Stresses, obstacles and solutions – Australian and world perspectives

What is obvious from the Australian experience is that any new program is difficult to implement in a primary care health system that is stressed. This was a theme that was also raised in the plenary sessions, when interventions for various diseases were discussed. GP and patient options are limited by the system in which the GP practices, and medications or treatments cheaply available in Europe, for example, may be prohibitively costly in another country. This relates equally to the time the GP has available to give to the individual patient. There is simply no ‘one size fits all’ solution to these issues, and the conference was a terrific forum for the exchange of examples and ideas on what works under this circumstance, or that.

 Useful Resource

The International Primary Care Respiratory Group

Developments in primary care in the UK

An opportunity … to meet Sue Cross

The Primary Care sector in the UK has been undergoing significant change over recent years and there will be an opportunity in November 2006 to hear from one of the people at the centre of those changes.

Since 2005, Sue Cross has been the National Project Manager of the General Practice Nursing Project: General Practice Nursing – Getting it Right for Patients and Public Health, in the Working in Partnership Program (WiPP).

WiPP seeks to:

• implement new ways of working, including team based care and new skill mixes,

• develop the public’s capacity to self care and manage minor illnesses and develop and deliver effective,

• integrated self-care services, largely provided by the community and voluntary sectors, and

• reduce reliance on mainstream NHS services

WiPP was established under the new (UK) General Medical Services contract to develop and implement a strategy for general practice to use clinician’s time effectively whilst improving availability of services for patients. Thirteen initiatives have been developed, of which the GP Nursing Project is one. This initiative supports the development of general practice nursing in order to improve recruitment and retention, facilitate a broader skills mix, raise standards and minimise risk.

Sue is well known internationally and in the UK through her work as Director of Training at the National Asthma and Respiratory Training Centre in Warwick (UK) and as International Project Manager of the Respiratory Education Resource Centre in Liverpool, developing respiratory training for health professionals ‘abroad’. She has been closely involved in the development of the nurse practitioner role in the UK and through the International Council of Nurses. More recently, Sue was Associate Director of Primary Care Nursing for Bedfordshire and Hertfordshire until her appointment to WiPP.

Venue: Pfizer Australia’s Lord Florey Learning and Conference Centre, 38-42 Wharf Road, West Ryde, NSW

Cost: No charge

Flyer: An opportunity … to meet Sue Cross and hear about developments in Primary Care in the UK

Further information: Contact Associate Professor Ron Tomlins

                                      Phone 02 9484 0050
                                      Fax 02 9484 0073
                                      Email rtomlins@ozemail.com.au 

Note: Mrs Cross’ trip has been supported by an unrestricted educational grant from Pfizer Australia.

See also:  Patient-Centred Health Care

Monitoring symptoms or peak flow?

Written Asthma Action Plans for Children

The provision of a Written Asthma Action Plan (WAAP) provides parents with a clear, succinct, written summary of their child’s asthma management. A recent review of the Cochrane database highlights the benefit of a WAAP preventing asthma exacerbations.¹

The aim of the review was to find randomised controlled trials (RCTs) where the only difference between groups of children was the provision or not of a WAAP.

Trials were included if they compared a WAAP with no WAAP, or different WAAPs with each other.

Perhaps a little surprisingly, the review authors found only four trials (three RCTs and one quasi-RCT) involving 355 children that fitted their criteria. The results of these trials showed that:

• Children using symptom-based WAAPs had lower risk of exacerbations which required an acute care visit (N = 5; RR 0.73; 95% CI 0.55 to 0.99). The number needed to treat to prevent one acute care visit was 9 (95% CI 5 to 138)

• Symptom monitoring was preferred over peak flow monitoring by children (N = 2; RR 1.21; 95% CI 1.00 to 1.46), but parents showed no preference (N = 2; RR 0.96; 95% CI 0.18 to 2.11). ).

• Children assigned to peak flow-based action plans reduced by 1/2 day the number of symptomatic days per week (N = 2; mean difference: 0.45 days/week; 95% CI 0.04 to 0.26).

• There were no significant group differences in the rate of exacerbation requiring oral steroids or admission, school absenteeism, lung function, symptom score, quality of life, and withdrawals.

The authors concluded that the evidence suggested that symptom-based WAAP was superior to peak flow WAAP for preventing acute care visits. However, there was insufficient data to firmly conclude whether the observed superiority was due to

• greater adherence to the monitoring strategy,
• earlier identification of onset of deteriorations,
• higher threshold for presentation to acute care settings, or
• the specific treatment recommendations.

It may not be clear why, but reduced exacerbations for parents can mean a child is spending less time out of normal routine school or other activity. Certainly that is a benefit worth having with WAAP.

Useful Resource

Asthma Action Plans

Reference

1. Bhogal S, Zemek R, Ducharme FM. Written action plans for asthma in children. Cochrane Database Syst Rev. 2006 Jul 19;3:CD005306.

Research Funding Opportunities