ARIA Phase 4 (2018): Change management in allergic rhinitis and asthma multimorbidity using mobile technology Abbreviations AHA: Active and healthy ageing AIRWAYS ICPs: Integrated care pathways for airway diseases AIT: Allergen immunotherapy AR: Allergic rhinitis ARIA: Allergic Rhinitis and its Impact on Asthma CDSS: Clinical decision support system CM: Change management CM2: Second phase of change management DG CONNECT: Directorate General for Communications Networks, Content & Technology DG Santé: Directorate General for Health and Food Safety DG: Directorate General EAACI: European Academy of Allergy and Clinical Immunology EFA: European Federation of Allergy and Airways Diseases Patients’ Associations EIP on AHA: European Innovation Partnership on Active and healthy ageing EIP: European Innovation Partnership ELF: European Lung Foundation EQ-5D: Euroquol ERS: European Respiratory Society EUFOREA: European Forum for Research and Education in Allergy GARD: WHO Global Alliance against Chronic Respiratory Diseases HCP: Health care professional ICP: Integrated care pathway IT: Information technology JA-CHRODIS: Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle MACVIA-LR: contre les MAladies Chroniques pour un VIeillissement Actif (Fighting chronic diseases for AHA) MASK: MACVIA-ARIA Sentinel network mHealth: mobile health OTC: Over the counter POLLAR: Impact of air POLLution on Asthma and Rhinitis QOL: Quality of life SCUAD: Severe chronic upper airway disease SDM: Shared decision making TRL: Technology Readiness level VAS: Visual analogue Scale WHO: World Health Organization WPAI-AS: Work Productivity and Activity questionnaire Introduction Allergic rhinitis (AR) is the most common chronic disease worldwide. Guidelines have improved the knowledge on rhinitis and made a significant impact on AR management. However, many patients are unsufficiently controlled and the costs for society are enormous, in particular due to AR major impact on school and work productivity 1. Unmet needs have clearly identified many gaps.
Allergic Rhinitis and its Impact on Asthma (ARIA) has evolved from a guideline using the best approach 2-6 to care pathways using mobile technology in AR and asthma multimorbidity 7. ARIA appears to be close to the patient’s needs but real life data obtained using an App in 22 countries have shown that very few patients use guidelines and that they often self-medicate (Bousquet, in preparation). Moreover, patients largely use OTC medications dispensed in pharmacies 8-10. Shared decision making (SDM) centered around the patient should be used more often. ARIA has followed a change management (CM) strategy but a new one should be considered to fill the gaps in order to increase the benefits of self-medication and SDM in care pathways using the currently-available IT tools 11. These changes should prepare and support individuals, teams and organizations in making organizational change centered around the patient. 1- Background 1-1- The four ARIA phases ARIA was initiated during a World Health Organization (WHO) workshop in 1999 (published in 2001) and has evolved in four phases (Figure 1): Phase 1: Development of an evidence-based document to provide a guide for the diagnosis and management of AR and asthma multimorbidity including developing countries 2,3. It was implemented by the WHO Collaborating Center for Asthma and Rhinitis (Montpellier). In 2008, ARIA was updated using the same recommendation system 2,12. ARIA has been disseminated and is implemented in over 70 countries around the world 13. 2: In its 2010 Revision, ARIA was the first chronic respiratory disease guideline to adopt the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach, an advanced evidence evaluation methodology 4-6. Phase 3: ARIA focussed on the implementation of emerging technologies for individualized and predictive medicine to develop care pathways for the management of AR and asthma by a group which included patients 14-20 (MASK: MACVIA (Contre les MAladies Chroniques pour un VIeillissement Actif)-ARIA Sentinel Network). The next phase is change management. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers and to those with asthma multimorbidity across the life cycle whatever their sex or socio-economic status in order to reduce health and social inequities incurred by the disease. Figure 1: The 4 Phases of ARIA
One of the ARIA strengths has been to communicate its vision powerfully and convincingly worldwide. Over 1,000 papers have been posted on Pubmed from over 50 countries using the ARIA recommendations 13. The number of training sessions in over 70 countries cannot be counted. ARIA was endorsed by many governments and international organizations and ARIA recommendations have been used for the labeling of allergen immunotherapy. 2-2-5- Empower others to act on the vision Organizational processes and structures are in place and are aligned with the overall organizational vision. However, we need to continuously check for barriers and for people who are resisting change. We have always been implementing proactive actions to remove the obstacles involved in the process of change. ARIA has been recognized as the major rhinitis and asthma multimorbidity guideline for years in most countries except for the US and Japan. However, the recent US guidelines are using the approach of ARIA (GRADE: Grading of Recommendations, Assessment, Development and Evaluation) and recommendations are similar 46-48 to those of ARIA 6. The recent Japanese guidelines for AR are also making bridges with ARIA 49. 2-2-6- Generate short-term wins As proposed by Kotter 11, creating short-term wins early in the change process can give a feel of victory in the early stages of change instead of one long-term goal. The concept of asthma and rhinitis multimorbidity is now globally accepted without any doubt in developed and developing countries 50. It is now recognized that multimorbidity is independent of IgE-mediated allergy 51,52 and new phenotypes of severe airway diseases have been identified. The implementation of the multimorbid concept in clinical practice has a direct benefit for the patient for whom nasal symptoms are often more bothersome than asthma. 2-2-7- Consolidate gains and produce more change The goals of step 7 11 are to achieve continuous improvement by analysing the success stories individually and improving from those individual experiences. These goals are exactly those followed by ARIA for the past 18 years.. 2-2-8- Anchor new approaches in the culture and institutionalize the changes The goals of step 8 11 are met by the ARIA strategy: Discuss the successful stories related to change initiatives widely. Ensure that the change becomes an integral part of the practice and is highly visible. Ensure that the support of the existing as well as the new leaders continues to extend towards the change. 2-3- Drawbacks and solutions based