The new model of health care organization for patients with asthma assumes changes at all levels of the health care system

At the initiative of the Polish Society of Allergology, the leader of the Coalition for the Treatment of Asthma, a press conference was held, during which the organizers and the authors of the report entitled Bronchial asthma – a new model of disease management aimed at increasing health value, presented recommendations for systemic changes to improve the quality of care for patients with asthma.

• Improving the effectiveness and optimization of treatment and increasing the professional activity of patients with asthma.
• Increasing the detection of asthma by family doctors and verification of the initial diagnosis of the disease and establishing an individual treatment plan for the patient by specialist doctors in the field of allergology and pulmonology.
• Reducing the number of hospitalizations of patients due to asthma exacerbations and transforming allergology departments into Severe Asthma Treatment Centers.

These are the main goals of the new asthma care organization model presented in this report. The document was developed by experts from the Lazarski University and clinicians specializing in the treatment of asthma. It covers the analysis of clinical, organizational and financial aspects of the diagnosis and treatment of an asthma patient in Poland. The recommendations presented in the report concern systemic changes aimed at improving the situation of people affected by this disease. The pursuit of their priority inclusion in the health care system is the goal of the Coalition for Asthma Treatment.

Evidence of successful asthma management is well documented, and many of the treatment optimization tools can be implemented at the lowest level of the system, i.e. primary care (primary care). It is the family doctor who should be the first point of contact for patients with bronchial asthma in health care systems. However, providing continuous and coordinated care throughout the life cycle of the disease, especially for people suffering from chronic diseases, requires the use of new solutions, including the model of integrated primary and outpatient care and a clear path for a patient with severe asthma to reach an advanced therapy center. An important tool supporting effective asthma control may be the e-Prescription system and modern e-Health solutions supporting doctors in the process of making therapeutic decisions – says Dr. Małgorzata Gałązka-Sobotka, Dean of the Lazarski University Postgraduate Education Center.

The most important challenges in treating asthma in Poland

Asthma is a chronic disease with a high incidence rate (2.2 million people in Poland, ie approx. 6% of the adult population). It places a heavy burden on both the patient and the healthcare system. Its treatment is long and costly. Among all allergic diseases, it is the most common cause of sickness absenteeism, hospitalization or long-term inability to work.

The goal of asthma treatment is to gain complete control of your asthma symptoms. It is also important to prevent exacerbations and not to worsen the patient’s health.

Assessing the current control of the disease is of key importance for further therapeutic decisions. Difficulties in recognizing asthma correctly and in gaining control of its symptoms are the main difficulties encountered in caring for an asthma. In Poland, many people with typical symptoms of asthma, such as coughing, wheezing, shortness of breath, are not diagnosed for a long time. More than 7 years pass from the first symptoms of the disease to the correct diagnosis. On the other hand, underdiagnosis is as high as 70%. 

The authors of the above-mentioned of the report indicate that our country does not meet the global standards of asthma management related to its control, i.e. not all allergists, pulmonologists, and family doctors are able to correctly assess the level of disease control in accordance with international guidelines. Even 50% of them do not comply with the current recommendations. 

The key guidelines for the therapeutic management of patients with asthma, recognized by the Polish Society of Allergology, are the international standards of the Global Initiative Against Asthma (GINA). The latest guidelines indicate that in the symptomatic treatment of asthma, the use of inhaled drugs, i.e. short-acting beta-2-agonists (SABA), should be limited. Their abuse may result in exacerbation of the disease, while the use of 3 or more doses per week increases the risk of future asthma attacks, and in the case of 12 and more packages per year – the risk of death from asthma.

Unfortunately, asthma patients overuse their SABA reliever inhalers. Research conducted in Poland as part of the ASTMA ZERO project (2019-2020) has shown that the average consumption of SABA by a Polish patient is 3.66 packages per year. On the other hand, 6% of respondents suffering from asthma and using drugs from this group use more than 12 packages per year.

Significant abuse of SABA can lead to exacerbations of asthma requiring the administration of high doses of oral glucocorticosteroids (GCS). Even small doses of these drugs significantly increase the risk of serious side effects, such as type 2 diabetes, pneumonia, osteoporosis, and cardiovascular diseases. According to the recommendations of GINA, the use of dGKS should be limited only to the most severe forms of asthma – if no other available treatment methods, including biological drugs, bring any improvement in the patient’s condition. Nevertheless, oral glucocorticosteroids are widely used in the treatment of patients with asthma

According to GINA standards, cases of asthma in which disease control is difficult should be referred to specialist centers for further diagnosis and implementation of biological treatment available under the drug program. Experts estimate that up to 32,000 patients may have severe asthma amenable to this therapy. Although biological treatment is effective at the level of over 90%, it reduces the frequency and severity of disease exacerbations quickly after implementation, and improves lung function – patients have limited access to this therapy or its continuation. In Poland, until the end of 2019, only 988 patients were receiving benefits under the drug program.

This state of affairs is caused by the low awareness of severe asthma among patients and doctors, and the lack of proper cooperation between doctors diagnosing patients and medical entities offering biological treatment. In addition, the possibility of implementing and implementing this treatment in patients with severe asthma is subject to the provisions of the drug program, which sometimes do not comply with clinical standards of treatment.

A model of organization of care for patients with asthma based on the concept of Value Based Healthcare

According to the authors of the report, in order to limit the negative effects caused by problems related to asthma, treatment of this disease should be considered as a priority of the Polish health care system. A disease management program should provide continuous, comprehensive, coordinated patient care at national and local levels.

The assumptions of the Polish asthma treatment strategy should take into account the systemic conditions in our country and the positive solutions introduced in other countries, with particular emphasis on Scandinavian achievements. The implementation of the strategy should involve medical communities, i.e. family doctors and specialists in the field of allergology, pulmonology and lung diseases who support them. It is crucial to monitor the health and economic effectiveness of the implemented programs in order to evaluate them and make a decision on their continuation or modification.

The Polish asthma treatment strategy should include the implementation of mechanisms within the framework of accounting for health care services, financially rewarding appropriate treatment in accordance with clinical standards and achieving appropriate asthma control. These mechanisms should cover all levels of the health care system, ie primary health care (POZ), outpatient specialist care (AOS), and hospital treatment.

The prepared report also defines tasks for each level of the health care system. The main goal of family doctors should be the initial diagnosis of asthma, and then continuation of treatment proposed by a specialist doctor in an individual treatment plan and monitoring of the patient’s current health condition. On the other hand, specialists, allergists and pulmonologists should verify the initial diagnosis of asthma, establish an individual treatment plan and consult chronic patients in the event of deteriorating health.

The key issue related to the modification of the organization of asthma treatment in Poland is the reduction of the number of hospitalizations of patients due to asthma exacerbations in hospital departments, as well as the transformation of allergology departments into Severe Asthma Treatment Centers. They would provide access to comprehensive treatment of patients with asthma in cases where outpatient treatment does not achieve the desired clinical results.

The extension of the e-Prescription functionality will support the doctor’s work

Experts indicate that it is necessary to implement IT solutions that would support the physician in the process of disease management in accordance with the GINA guidelines and would be helpful in selecting the best therapy for a patient with asthma. Such possibilities are created by the e-Prescription system. The use of its functionality would support the family doctor in effective asthma control by monitoring the amount of medications taken (SABA, dGKS) against the recommendations contained in clinical guidelines. At the time of issuing the prescription, the doctor would receive feedback (alert) from the e-Prescription system about the risk of abuse of specific groups of drugs by the patient.

Extending the e-Prescription with additional tools does not require the collection of new categories of data, but only the processing of data already collected in accordance with the applicable treatment guidelines and the exchange of information between the Internet Patient Account (IKP) and the prescription system used by the doctor.

For every doctor, the necessary information is the amount of drugs and at what time the patient is taking. This allows you to judge whether they are used in accordance with medical guidelines or not abused. With this knowledge, the clinician can modify the therapeutic regimen to optimize the patient’s treatment.

Joint action to improve the state of asthma treatment in Poland

n the field of building dialogue and cooperation to improve the diagnosis and treatment system of asthma in Poland, it is crucial to create a platform associating representatives of clinicians, expert communities and patient organizations. Speaking with a common voice by a wide body of stakeholders will allow the recommendations to be resonated with greater force. Such an initiative is the Coalition for Asthma Treatment – an association of people and institutions directly interested in the systemic aspects of asthma treatment in Poland. Coalition members recognize the need to urgently improve the availability and quality of asthma treatment in Poland and to provide patients with holistic care, based on modern therapies, in accordance with the latest treatment standards.

The direction of work will be determined by the Coalition Presidium, which will include clinicians, national consultants, system experts and representation of the patient community. This team will jointly define systemic projects, and their implementation will be entrusted to working groups dedicated to individual projects. Priority is given to projects that will be able to relatively quickly improve the detection and quality of treatment of patients with asthma. An interesting tool, in the opinion of the Asthma Treatment Coalition, are e-health systems, such as e-Prescription, which enable the detection of the risk of abuse, in the light of the applicable GINA standards, of specific groups of drugs.