The fact that most healthcare resources are spend on a small subgroup of patients with an unfavourable prognosis has long been recognized. Therefore change is needed in terms of an improved... Show moreThe fact that most healthcare resources are spend on a small subgroup of patients with an unfavourable prognosis has long been recognized. Therefore change is needed in terms of an improved identification of patients with an unfavourable prognosis, early in their treatment course, which may facilitate proactive approaches to improve outcomes. We discussed two conceptually distinct constructs of predictors of prognosis in order to improve the identification of patients with an unfavourable prognosis. First, the level of control of the chronic condition as a predictor could reflect to some extent the presence of a multitude of other risk factors. Second, information on early treatment response had better predictive ability for long-term outcomes and so acts as a proxy for treatment effectiveness. Treatment effectiveness depends on different aspects e.g. adequateness of initial treatment and/or drugs, the mutual trust between clinician and patient and behavioral aspects such as treatment adherence. Treatment response adds an insight that can be acted upon; guiding personalized decisions in the treatment plan. In conclusion, this thesis leads to improvement of personalized medicine and thereby could increase the efficient use of healthcare resources, with the early identification of patients at risk of an unfavourable prognosis. Show less
Background: The aim of this study was to identify patients who benefit most from exhaled nitric oxide fraction (F-ENO)-driven asthma management in primary care, based on prespecified subgroups with... Show moreBackground: The aim of this study was to identify patients who benefit most from exhaled nitric oxide fraction (F-ENO)-driven asthma management in primary care, based on prespecified subgroups with different levels of F-ENO.Methods: We used data from 179 adults with asthma from a 12-month primary care randomised controlled trial with 3-monthly assessments of F-ENO, asthma control, medication usage, costs of medication, severe asthma exacerbations and quality of life. In the original study, patients were randomised to either a symptom-driven treatment strategy (controlled asthma (Ca) strategy) or a F-ENO+symptomdriven strategy (FCa). In both groups, patients were categorised by their baseline level of F-ENO as low (<25 ppb), intermediate (25-50 ppb) and high (>50 ppb). At 12 months, we compared, for each prespecified F-ENO subgroup, asthma control, asthma-related quality of life, medication usage, and costs of medication between the Ca and FCa strategy.Results: We found a difference between the Ca and FCa strategy for the mean dosage of beclomethasone strategy of 223 mu g (95% CI 6-439), p=0.04) and for the total costs of asthma medication a mean reduction of US$159 (95% CI US$33-285), p=0.03) in patients with a low baseline F-ENO level. No differences were found for asthma control, severe asthma exacerbations and asthma-related quality of life in patients with a low baseline F-ENO level. Furthermore, in patients with intermediate or high level of F-ENO, no differences were found.Conclusions: In primary care, F-ENO-driven asthma management is effective in patients with a low F-ENO level, for whom it is possible to down-titrate medication, while preserving asthma control and quality of life. Show less
Boer, S.; Dekkers, O.M.; Cessie, S. le; Carlier, I.V.E.; Hemert, A.M. van 2019
