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.

Primary prevention

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:

·          allergenic exposure and sensitization;

·          cigarette smoking and tobacco environmental exposure;

·          indoor and outdoor pollution; and

·          changes 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.

Secondary prevention

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 national levels.

Research

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 targets.

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.

More studies are needed to investigate which factors influence the development of asthma and allergy and to assess the reasons for the recent increase in the frequency and severity of rhinitis in Europe.

Policies

At policy level the most important recommendations are focused in the EU on :

1.      promoting healthy lifestyles

2.      strengthening the disease management approach for asthma patients as well as for other chronic diseases;

3.      monitoring asthma 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 process.

In general, two  levels of 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.