Treating the mind and the body
Thys van der Molen
Disclosures/ conflict of interest
• Reimbursement for travel, research grants,
consultation fees and fees for presentations from:
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Almirall
AstraZeneca
Boehringer Ingelheim
GlaxoSmithKline
Mundipharma International
TEVA
UMCG
Lung foundation
EU projects
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Scientific interest
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Co Founder of the IPCRG
Co Founder of the Asthma COPD service
Co founder of the Mulago hospital Lung institute
Developer of Clinical COPD Questionnaire (CCQ)
Co investigator /developer of the COPD Assessment Test (CAT)
Developer of the Bronchial Hyperesposiveness Questionnaire (BHQ)
Developer of the Inhaled Corticosteroid side effect Questionnaire (ICQ)
Developer of the Asthma COPD service (AC)
Developer of the Small Airways Disease Tool (SADT)
Co investigator ABC tool
Co investigator Connecare H 2020
Co investigator of the PRO-active tool
Co investigator of the ASAP study
The Asthma patient : treating the mind and
the body during the consultation
curing the disease only is not sufficient, and care of the patient is of tantamount importance
The asthma patient
Female 34 years Spirometry
Female, 34 years
Patient history:
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•
•
•
•
•
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•
Reason for visit:
occupation:
smoking pattern:
Familial:
Clinical history:
Atopy:
perfume air, exertion
Exacerbations:
Disease timecourse:
Medical treatment:
Asthma?
Housewife
current smoking
yes
eczema, allergy
seasons, fog,
2 (last year)
since age of 29
none
CCQ:
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•
•
•
•
•
•
•
•
•
•
Total: 3,3
CCQ1 short of breath at rest:
CCQ2 short of breath at exertion:
CCQ3 concerned:
CCQ4 depressed:
CCQ5 cough:
CCQ6 produce phlegm:
CCQ7 strenuous physical activities:
CCQ8 moderate physical activities:
CCQ9 daily activities at home:
CCQ10 social activities:
6
6
2
0
6
6
4
2
1
0
Total: 2,2
ACQ1 how often wake up at night:
ACQ2 symptoms in the morning:
ACQ3 limit of usual activities:
ACQ4 short of breath:
ACQ5 wheezing:
ACQ6 using of rescue medication:
1
3
3
3
3
0
ACQ:
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•
•
•
•
•
•
MRC:
• Total: 3
Conclusion patient
• Asthma or ACOS
• Untreated
• GINA? (Step 0)
• Real question is why is she untreated?
The Asthma patient what kind of
mental care does the patient need?
Benedetti Physiol review 2013
Asthma Patient beliefs and attitudes
influence behaviour towards disease
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Fear
Confidence
Self efficacy
Self esteem
Disease severity idea’s
Relation with HCP
Idea’s about medication
Effect
Side effects
All very chemical !!
Many patients are uncontrolled!(realise study)
GINA-defined current asthma control
Perception of asthma seriousness
16%
20%
45%
35%
Uncontrolled
Controlled
83%
Partially Controlled
Not serious
Serious
Base: all respondents from the country-specific analysis, N = 7457
Asthma control was assessed using GINA (Global Initiative for Asthma) criteria
Q: How serious do you consider your asthma to be at the moment? Answers were combined: serious (very; fairly serious); not serious (not very; not at all serious)
11
But what do we want to influence?
The value of the consultation
But what do we want to influence?
And what questions should we ask?
Cluster analysis of asthma patients
beliefs and attitudes the realise study
To understand patients’ differing behaviour & attitudes towards managing their asthma, we performed factor
analysis, followed by cluster analysis.
Questions
describing
asthma patient
attitudes and
behaviours
[Q2,Q34a,Q39,
Q46, Q48]
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Attitudinal
Variables
Responses were
dichotomized to account for
country differences in using
agreement scale
Impact on
Activities of
Daily Living
Deprioritising
health
8
Socially conscious
about asthma
Acceptance of
asthma label
Stress in daily
life
asthma
Anxious about
asthma
Summary
Factors
Dependence in
Actionable
Patient
Segments
Confidence in
doctor
Use of GINA-defined control status as a covariate*
*Being a covariate means that the GINA-defined status has an effect added to or subtracted from the factors used for segmentation, so GINA-defined status does not have an effect
in itself but it modifies the way the other measures affect segment allocation. Thus segmentation model performance is improved when GINA-defined control status is taken into
consideration during regression analysis.
REALISE Global Segmentation Discussion
Slide 16
Cluster analysis of asthma patients
attitudes towards their disease
Segment 1
INDIFFERENT
Segment 2
WORRIER
Segment 3
WELL
ADJUSTED
Segment 4
DEPENDENT
Segment 5
LOST
Moderate
Lowest
Highest
Moderate
Low
Level of confidence in
managing asthma
High
Low
Highest
High
Low
Perceived severity of
asthma
Not serious
Serious
Not serious
Moderate
Serious
Frequency of seeking
information about asthma
Low
High
Lowest
Moderate
Highest
Level of concern about their
asthma
Low
Moderate
Lowest
Low
Moderate
Moderate
Moderate
Low
Low
Highest
Level of asthma control
(Gina-defined control
status)
Socially conscious about
asthma
Base: All respondents n=7930 [ Seg1 (2782), Seg2 (2194), Seg3 (2044), Seg4 (442), Seg5 (468)]
REALISE Global Segmentation Discussion
Slide 17
Attitude and behaviour might be
more important than control!
Segment 1
INDIFFERENT
33%
67%
Segment 2
WORRIER
Male
Female
Age Profile
45%
55%
Segment 3
WELL ADJUSTED
Male
Female
31 to 40
41 to 50
Gina-defined control status
Uncontrolled
19% 30%
38%
30%
50%
43%
Male
34%
34%
46%
Female
Male
54%
Female
Age Profile
30%
32%
34%
45%
21%
32%
18 to 30
31 to 40
41 to 50
Gina-defined control
status
13%
Partly
controlled
Controlled
57%
Age Profile
30%
18 to 30
Male
Age Profile
37%
33%
35%
66%
Female
Age Profile
35%
34%
Segment 5
LOST
Segment 4
DEPENDENT
86%
REALISE Global Segmentation Discussion
Uncontrolled
18 to 30
31 to 40
41 to 50
Gina-defined control
status
Uncontrolled
10%
Partly
controlled
Controlled
48%
42%
Partly
controlled
Controlled
18 to 30
31 to 40
41 to 50
Gina-defined control
status
Uncontrolled
12%
41%
48%
Partly
controlled
Controlled
18 to 30
31 to 40
41 to 50
Gina-defined control
status
Uncontrolled
14%
84%
Partly
controlled
Controlled
Slide 18
The value of the consultation
But what do we want to influence?
And what questions
should we ask?
• Level of confidence in managing
asthma
• Do you think that you can learn to
handle your respiratory condition?
• How severe do you think your
respiratory condition is?
• Would you like to have more
information?
• How concerned are you about your
respiratory condition
• Do you think you have asthma ?
• ma
• Frequency of seeking information
about asthma
• Level of concern about their asthma
• Socially conscious about asthma
Cluster analysis of asthma patients
attitudes towards their disease
Segment 1
INDIFFERENT
Segment 2
WORRIER
Segment 3
WELL
ADJUSTED
Segment 4
DEPENDENT
Segment 5
LOST
Moderate
Lowest
Highest
Moderate
Low
Level of confidence in
managing asthma
High
Low
Highest
High
Low
Perceived severity of
asthma
Not serious
Serious
Not serious
Moderate
Serious
Frequency of seeking
information about asthma
Low
High
Lowest
Moderate
Highest
Level of concern about their
asthma
Low
Moderate
Lowest
Low
Moderate
Moderate
Moderate
Low
Low
Highest
Level of asthma control
(Gina-defined control
status)
Socially conscious about
asthma
Base: All respondents n=7930 [ Seg1 (2782), Seg2 (2194), Seg3 (2044), Seg4 (442), Seg5 (468)]
REALISE Global Segmentation Discussion
Slide 20
Stepwise approach to control asthma symptoms
and reduce risk
NEW!
GINA 2014, Box 3-5
© Global Initiative for Asthma
Stepwise approach to control asthma symptoms
and reduce risk
Mental /
attitude
phenotyping
NEW!
GINA 2014, Box 3-5
© Global Initiative for Asthma
Shared decision making
Shared decision making
Shared decision making
S Wilson et al Amjcrcmed 2010
Stepwise approach to control asthma symptoms
and reduce risk
Mental /
attitude
phenotyping
NEW!
GINA 2014, Box 3-5
© Global Initiative for Asthma
Conclusions
• Assessment of patients attitudes and beliefs
might be more important than assessment of
symptoms or control
• A mental assessment could help in treating
the mind
• Shared decision making proved to influence
patient behaviour
Thank you!