5.9.5. Control tools and policies
For a better assessment of the cost-benefit ratio of
therapy and management measures, it would be useful if figures and costs
related to the major allergic diseases were included in all health statistics.
Studies such as the ISAAC keep in bringing new information
about the places where risk factors conditions are progressively rising as
lifestyle, occupational and other environmental factors. The main determinants
considered in primary prevention policies at the moment are:
exposure and sensitization;
smoking and tobacco environmental exposure;
and outdoor pollution; and
in dietary habits.
For the primary prevention approaches of the asthma and
allergenic rhinitis related to lifestyles or the environment see Chapter 5. A key message related to the importance of healthy settings – houses, places of employment, schools
and cities - should have mechanisms to ensure that people are exposed as little
as possible to the risky allergens. Greater attention should be focused on preventive
measures, patient education and self-management programmes.
Major efforts are needed to redress this situation; at first, by generating
additional expenditures for health care systems, but also reducing the costs of
allergic care to society as a whole.
The organization of health care has to be reconsidered on
a national and international basis, to provide greater harmonization and
effectiveness of health care systems and professional training in allergology.
High quality assessment criteria must be introduced, together with scientific
and evidence-based preventive measures and guidelines for diagnosis and
treatment of proven efficacy. Prevention requires a more precise identification
of atopic individuals, even from the very first infancy, when possible, and a
deeper knowledge of risk factors in the aetiology of allergic disorders. A
better implementation of treatment guidelines requires more education of both
patients and doctors that is crucial for the improvement of asthma management.
Most asthma cases are self-managed by patients with the support of general
practitioners and nurses. General practitioners should encourage a personal
self-management of asthmatic symptoms; in reality, also primary health care
teams must be strengthened with the patients, in order to create a close
cooperation and a productive bidirectional interaction between the two. There
is a paucity of literature describing the implementation of clinical
performance improvement (CPI) efforts across geographically dispersed
multispecialty group practices and independent practice associations. PhyCor, a
physician management company based in Nashville, Tennessee, has integrated CPI
initiatives into its operating infrastructure (Loeppke, 1999). The strategic
framework guiding PhyCor's CPI initiatives is built around a physician-driven,
patient-centered model. Physician/administrator leadership teams develop and
implement a clinical and financial strategic plan for performance improvement;
adopt local clinical and operational performance indicators; and agree on and
gain consensus with local physician champions to engage in CPI initiatives.
Physician leadership and strategic vision, CPI-oriented organizational
infrastructure, providing access to performance data, parallel incentives, and
creating a sense of urgency for accelerated change are all critical success
factors for the implementation of CPI strategies at local, regional, and
The Quality of life and management of human resources
programme28 under the Fifth Framework Programme for Research is already
supporting studies made by over 50 European teams, many of them also
cooperating with laboratories in EU-applicant countries. Some are concerned
specifically with asthma and the aetiology of allergies, some with food
allergens and some with methods of diagnosis and treatment strategies. The
emphasis is clearly on prevention.
The GA²LEN (Global Allergy
and Asthma European Network) is a research network (funded by the European Commission's
6th Framework Programme for Research) working to create a permanent and durable
structure to coordinate research capacity in Europe on Allergy and Asthma
issues coordinated by the University of Gent (Belgium) with the objective to
establish an internationally competitive network, to enhance the quality and
relevance of research, address all aspects of the disease and eventually to
decrease the burden of allergy and asthma throughout Europe.
Research efforts should contribute to achieving a better
understanding of the pathogenetic mechanisms and the development of
target-organ hyperresponsiveness and tissue damage leading to long-term
complaints and morbidity, in order to gain a better awareness of treatment
New anti-allergic drugs should be evaluated in terms of
both immediate benefits and long term direct and indirect costs and include the
improvement on the quality of life.
At policy level the most important recommendations are
focused in the EU on :
disease management approach for asthma patients as well as for other chronic
related deaths as an indicator of the quality of ambulatory care and adopting
audit procedures for these deaths as part of the total quality management
In general, two levelsf health care are to be considered. The first one is the primary
health care level in which general practitioners, paediatricians and nurses
carry out the very first assessment of patients. The second level is the
specialized care in which patients are referred to and for a final diagnosis,
treatment and clinical monitoring in severe cases. At this level there are
Pneumology (Respiratory Medicine) or Allergy Units run by specialists
(Pneumology or Allergy and some by both). At the moment there is not enough
scientific evidence of the effectiveness of these models of health care
organization and there is no recommendation for clinical guidelines. Many
patients are under-diagnosed and under-treated, but it is not still well known
to what extent these problems could be improved by the intervention onto the
health care systems.