1. Treating the mind and the body
Thys van der Molen

2. Disclosures/ conflict of interest
Reimbursement for travel, research grants, consultation fees and fees for presentations from:
Almirall
AstraZeneca
Boehringer Ingelheim
GlaxoSmithKline
Mundipharma International
TEVA
UMCG
Lung foundation
EU projects

3. Scientific interest 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

4. 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

5. The asthma patient

6. Female 34 years Spirometry

7. Female, 34 years Patient history: CCQ: ACQ: Total: 3,3
CCQ1 short of breath at rest: 6
CCQ2 short of breath at exertion: 6
CCQ3 concerned: 2
CCQ4 depressed: 0
CCQ5 cough: 6
CCQ6 produce phlegm: 6
CCQ7 strenuous physical activities: 4
CCQ8 moderate physical activities: 2
CCQ9 daily activities at home: 1
CCQ10 social activities: 0
ACQ:
Total: 2,2
ACQ1 how often wake up at night: 1
ACQ2 symptoms in the morning: 3
ACQ3 limit of usual activities: 3
ACQ4 short of breath: 3
ACQ5 wheezing: 3
ACQ6 using of rescue medication: 0
MRC:
Total: 3
Patient history:
Reason for visit: Asthma?
occupation: Housewife
smoking pattern: current smoking
Familial: yes
Clinical history: eczema, allergy
Atopy: seasons, fog, perfume air, exertion
Exacerbations: 2 (last year)
Disease timecourse: since age of 29
Medical treatment: none

8. Conclusion patient Asthma or ACOS Untreated GINA? (Step 0)
Real question is why is she untreated?

9. The Asthma patient what kind of mental care does the patient need?
Benedetti Physiol review 2013

10. Asthma Patient beliefs and attitudes influence behaviour towards disease
Fear
Confidence
Self efficacy
Self esteem
Disease severity idea’s
Relation with HCP
Idea’s about medication
Effect
Side effects
All very chemical !!

11. Many patients are uncontrolled!(realise study)
Respondent recruitment
The respondent population was drawn from validated consumer panels 
Multiple panels were used to reduce potential bias. Quality control measures (including the cross-referencing of Internet addresses) identified respondents registered on multiple panels; these respondents were excluded
iHARP/GINA-control questions assessed:
how many days in the past week respondents had daytime symptoms
how many days in the past week respondents had awoken at night
how many days in the past week respondents had their normal activities affected by asthma
how many times respondents had used a reliever inhaler
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)

12. But what do we want to influence?

13. Cognitive model, negative circle.
Dorthe Gaby Bove et al. BMJ Open 2015;5:e008031
©2015 by British Medical Journal Publishing Group

14. Cognitive model, positive circle.
Dorthe Gaby Bove et al. BMJ Open 2015;5:e008031
©2015 by British Medical Journal Publishing Group

15. The value of the consultation 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?

16. 34 Attitudinal Variables 8
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]
34 Attitudinal Variables
Impact on Activities of Daily Living
Socially conscious about asthma
Stress in daily life
Anxious about asthma
Confidence in doctor
Dependence in asthma
Acceptance of asthma label
Deprioritising health
Actionable Patient Segments 8
Summary Factors
Responses were dichotomized to account for country differences in using agreement scale
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.

17. 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
Level of asthma control (Gina-defined control status)
Moderate
Lowest
Highest
Low
Level of confidence in managing asthma
High
Perceived severity of asthma
Not serious
Serious
Frequency of seeking information about asthma
Level of concern about their asthma
Socially conscious about asthma
Base: All respondents n=7930 [ Seg1 (2782), Seg2 (2194), Seg3 (2044), Seg4 (442), Seg5 (468)]

18. Attitude and behaviour might be more important than control!
Segment 1
INDIFFERENT
Segment 2
WORRIER
Segment 3
WELL ADJUSTED
Segment 4
DEPENDENT
Segment 5
LOST
Base: All respondents n=7930 [ Seg1 (2782), Seg2 (2194), Seg3 (2044), Seg4 (442), Seg5 (468)]

19. The value of the consultation 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?
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

20. 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
Level of asthma control (Gina-defined control status)
Moderate
Lowest
Highest
Low
Level of confidence in managing asthma
High
Perceived severity of asthma
Not serious
Serious
Frequency of seeking information about asthma
Level of concern about their asthma
Socially conscious about asthma
Base: All respondents n=7930 [ Seg1 (2782), Seg2 (2194), Seg3 (2044), Seg4 (442), Seg5 (468)]

21. Stepwise approach to control asthma symptoms and reduce risk
NEW!
GINA 2014, Box 3-5

22. Stepwise approach to control asthma symptoms and reduce risk
Mental / attitude phenotyping
NEW!
GINA 2014, Box 3-5

23. Shared decision making

24. Shared decision making

25. Shared decision making
S Wilson et al Amjcrcmed 2010

26. Stepwise approach to control asthma symptoms and reduce risk
Mental / attitude phenotyping
NEW!
GINA 2014, Box 3-5

27. 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

28. Thank you!