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- mINSPIRERS – Estudo da exequibilidade de uma aplicação móvel para medição e melhoria da adesão à medicação inalada de controlo em adolescentes e adultos com asma persistente. Protocolo de um estudo observacional multicêntricoPublication . Jácome, Cristina; Guedes, Rui; Almeida, Rute; Teixeira, João Fonseca; Pinho, Bernardo; Vieira -Marques, Pedro; Vilaça, Rita; Fernandes, José; Ferreira, Ana; Couto, Mariana; Jacinto, Tiago; Pereira, Altamiro da Costa; Fonseca, João AlmeidaA má adesão à medicação inalada é um dos principais fatores que limita a melhoria clínica nos doentes com asma. Desta forma, é fundamental o desenvolvimento de ferramentas de monitorização de adesão à medicação objetivas e de fácil disseminação e a promoção de estratégias de adesão à medicação facilmente integráveis no dia a dia dos doentes. Os smartphones e jogos em comunidade virtual podem ter um papel relevante para a adoção de comportamentos promotores da saúde. Com bases nestes pressupostos foi desenvolvida a aplicação móvel InspirerMundi, com as suas componentes de monitorização, jogo e suporte por pares, para monitorizar e melhorar a adesão à medicação inalada de controlo em adolescentes e adultos com asma. O objetivo do estudo mINSPIRERS é avaliar a exequibilidade desta aplicação móvel. Estudo observacional prospetivo, multicêntrico composto por uma visita inicial e por três entrevistas telefónicas (após 1 semana, 1 mês e 4 meses) em cerca de 25 centros (Imunoalergologia, Pediatria, Pneumologia) de cuidados secundários em Portugal. Serão incluídos um mínimo de 20 adolescentes e 20 adultos com asma persistente. As principais dimensões avaliadas serão: adesão à medicação, crenças sobre a medicação, satisfação com o inalador, controlo da asma, exequibilidade técnica e padrões de utilização da aplicação, e a satisfação com a aplicação. A aplicação InspirerMundi pretende transformar a adesão à medicação inalada numa experiência positiva através de elementos de gamificação e suporte social, permitindo simultaneamente a monitorização verificada da adesão ao tratamento. É expectável que os resultados deste estudo contribuam não só para o aperfeiçoamento da aplicação InspirerMundi, mas também para informar o desenvolvimento de soluções mHealth e intervenções de melhoria da adesão à medicação em doentes com asma.
- FRASIS - Monitorização da função respiratória na asma utilizando os sensores integrados do smartphonePublication . Almeida, Rute; Amaral, Rita; Jacinto, Tiago; Amaral, RitaO projeto FRASIS pretende desenvolver, integrar e validar um conjunto de tecnologias de informação e comunicação (TIC) de saúde móvel (mHealth) para a monitorização remota da função respiratória na asma, usando apenas o smartphone e os seus sensores integrados. As ferramentas atuais de automonitorização e autogestão da asma são complexas, pouco atrativas, não individualizadas e obrigam os profissionais de saúde a análises trabalhosas, desmotivando a sua utilização e integração nos cuidados de saúde. Existe uma clara oportunidade para soluções tecnológicas avançadas económicas para os doentes e atrativas para os diferentes intervenientes do setor da saúde. A estratégia do FRASIS é desenvolver e integrar tecnologias de automonitorização e autogestão sem a necessidade de dispositivos adicionais, fazendo uso da presença dos smartphones na vida diária e da sua futura integração com sensores ambientais em cidades inteligentes. O FRASIS pretende assim contribuir para a concretização dos princípios da saúde digital e inovar nas tecnologias de monitorização remota da função respiratória. Espera - se que os resultados do FRASIS tenham um impacto relevante na inovação em serviços de saúde para a asma, com maior envolvimento e capacitação do doente, fornecendo informação prospetiva e de qualidade para uma melhor decisão clínica, tornando assim os cuidados de saúde mais eficientes e sustentáveis.
- Monitoring adherence to asthma inhalers using the InspirerMundi App: Analysis of real-world, Medium-term feasibility studiesPublication . Jàcome, Cristina; Amaral, Rita; Amaral, Rita"Poor medication adherence is a major challenge in asthma and objective assessment of inhaler adherence is needed. InspirerMundi app aims to monitor inhaler adherence while turning it into a positive experience through gamification and social support. We assessed the medium-term feasibility of the InspirerMundi app to monitor inhaler adherence in real-world patients with persistent asthma (treated with daily inhaled medication). In addition, we attempted to identify the characteristics of the patients related to higher app use. Two real-world multicenter observational studies, with one initial face-to-face visit and a 4-month telephone interview, were conducted in 29 secondary care centers from Portugal. During an initial face-to-face visit, patients were invited to use the app daily to register their asthma medication intakes. A scheduled intake was considered taken when patients took a photo of the medication (inhaler, blister, or others) using the image-based medication detection tool. Medication adherence was calculated as the number of doses taken as a percentage of the number scheduled. Interacting with the app ≥30 days was used as the cut-off for higher app use. A total of 114 patients {median 20 [percentile 25 to percentile 75 (P25–P75) 16–36] years, 62% adults} were invited, 107 (94%) installed the app and 83 (73%) completed the 4-month interview. Patients interacted with the app for a median of 18 [3–45] days, translated on a median use rate of 15 [3–38]%. Median inhaler adherence assessed through the app was 34 [4–73]% when considering all scheduled inhalations for the study period. Inhaler adherence assessed was not significantly correlated with self-reported estimates. Median adherence for oral and other medication was 41 [6–83]% and 43 [3–73]%, respectively. Patients with higher app use were slightly older (p = 0.012), more frequently taking medication for other health conditions (p = 0.040), and more frequently prescribed long-acting muscarinic antagonists (LAMA, p = 0.024). After 4 months, Control of Allergic Rhinitis and Asthma Test (CARAT) scores improved (p < 0.001), but no differences between patients interacting with the app for 30 days or less were seen. The InspirerMundi app was feasible to monitor inhaler adherence in patients with persistent asthma. The persistent use of this mHealth technology varies widely. A better understanding of characteristics related to higher app use is still needed before effectiveness studies are undertaken. "
- Understanding beliefs about inhaled medication in patients with persistent asthma: a cross-sectional analysis of the INSPIRERS studiesPublication . Novais, Catarina; Cruz, Ana Margarida; Pereira, Ana Margarida; Almeida, Rute; Amaral, Rita; Fonseca, João Almeida; Jácome, CristinaIdentifying factors influencing adherence, such as patients’ beliefs about medication, is essential for effective asthma management. This study aims to assess and gain insight into the beliefs of patients with asthma regarding inhaled medication. This is a secondary analysis of the INSPIRERS studies. Patients aged ≥ 13 y.o., with persistent asthma and a prescription for inhaled controller were recruited from 60 primary and secondary care centres in Portugal from 2017 to 2020. Demographic and clinical characteristics were collected in a face-to-face visit. The Specific-Beliefs about Medicine Questionnaire was administered 1-week later by telephone interview. Mann-Whitney U and Kruskal-Wallis tests were used to explore relations between patients’ beliefs and characteristics. A total of 552 participants (mean 32.8 ± 17.3 y.o.; 64.5% female) were analysed. The Necessity score (Median 19 [p25-p75 16,22]) was significantly higher than the Concerns score (15 [16,22], p < 0.001), resulting in a positive Necessity-Concern differential (Median 4 [0,7]). Acceptance (high necessity, low concerns) characterized 61% of participants, while 19% were ambivalent (high necessity, high concerns). Adolescents exhibited lower Necessity (Median 16 vs 20; p < 0.001) and Concerns scores (Median 11 vs 15; p = 0.002) than adults. In primary care setting, patients had significantly lower Necessity (Median 18 vs 19; p = 0.027) and Concerns (Median 14 vs 15; p = 0.05) compared to the secondary care. A predominantly positive perception of inhaled asthma medication necessity was found, although ambivalence or indifference exists in about 1/5 of patients. Our findings highlight the importance of personalized approaches to address beliefs and optimise patient education.
- Patients' health care resources utilization and costs estimation across cardiovascular risk categories: insights from the LATINO studyPublication . Gavina, Cristina; Borges, Alexandra; Afonso-Silva, Marta; Fortuna, Inês; Canelas-Pais, Mariana; Amaral, Rita; Costa, Inês; Seabra, Daniel; Araújo, Francisco; Taveira-Gomes, Tiago; Amaral, Rita"Atherosclerotic Cardiovascular Disease (ASCVD) is a global public health concern. This study aimed to estimate the healthcare resource utilization (HRU) and costs stratified by cardiovascular disease (CVD) risk categories using real-world evidence, in a regional population in Portugal. This is a retrospective observational study, using data from Electronic Health Records between 2017 and 2021. Patients aged≥40 years, and with at least one general practitioner (GP) appointment in the 3 years before 31st of December 2019, were included. CVD risk categories were determined based on 2021 ESC prevention guidelines. HRU encompassed hospital data (hospitalizations, outpatient and emergency room visits) and GP appointments. Total direct costs per patient were calculated based on the reference cost of the Portuguese legislation for payment methodology on Diagnosis-Related Groups (DRGs). Analysis of 3 122 695 episodes, revealed consistent HRU and costs across the five years. Very high-risk patients, showed higher HRU, particularly in hospital admissions. Costs tended to rise with higher CVD risk level. Very high-risk patients with ASCVD had higher costs for hospital admissions, while low-to-moderate risk patients had higher costs for GP visits. Despite a smaller proportion, very high-risk patients with prior ASCVD represent the highest costs per patient across healthcare settings (from 115€ in emergency visits to 2 673€ in hospitalizations), followed by very high-risk patients without prior ASCVD (ASCVD-risk equivalents). This study revealed a substantial HRU and costs by patients with very high CVD risk, particularly those with prior ASCVD. Moreover, ASCVD-risk equivalents emerge as notable consumers, emphasizing the importance of risk assessment and preventive measures in cost-effective management of these patients. "
- Identification of clusters of asthma control: a preliminary analysis of the Inspirers studiesPublication . Almeida, João; Amaral, Rita; Amaral, RitaTo identify distinct asthma control clusters based on Control of Allergic Rhinitis and Asthma Test (CARAT) and to compare patients’ characteristics among these clusters. Adults and adolescents (≥13 years) with persistent asthma were recruited at 29 Portuguese hospital outpatient clinics, in the context of two observational studies of the INSPIRERS project. Demographic and clinical characteristics, adherence to inhaled medication, beliefs about inhaled medication, anxiety and depression, quality of life, and asthma control (CARAT, >24 good control) were collected. Hierarchical cluster analysis was performed using CARAT total score (CARAT -T). 410 patients (68% adults), with a median (percentile 25–percentile 75) age of 28 (16 -46) years, were analysed. Three clusters were identified [mean CARAT -T (min -max)]: cluster 1 [27(24 -30)], cluster 2 [19(14 -23)] and cluster 3 [10(2 -13)]. Patients in cluster 1 (34%) were characterised by better asthma control, better quality of life, higher inhaler adherence and use of a single inhaler. Patients in clusters 2 (50%) and 3 (16%) had uncontrolled asthma, lower inhaler adherence, more symptoms of anxiety and depression and more than half had at least one exacerbation in the previous year. Furthermore, patients in cluster 3 were predominantly female, had more unscheduled medical visits and more anxiety symptoms, perceived a higher necessity of their prescribed inhalers but also higher levels of concern about taking these inhalers. There were no differences in age, body mass index, lung function, smoking status, hospital admissions or specialist physician follow -up time among the three clusters. An unsupervised method based on CARAT--T, identified 3 clusters of patients with distinct, clinically meaningful characteristics. The cluster with better asthma control had a cut -off similar to the established in the validation study of CARAT and an additional cut -off seems to distinguish more severe disease. Further research is necessary to validate the asthma control clusters identified.
- Concepts for the Development of Person-Centered, Digitally Enabled, Artificial Intelligence–Assisted ARIA Care Pathways (ARIA 2024)Publication . Bousquet, Jean; Amaral, Rita; Amaral, RitaThe traditional healthcare model is focused on diseases (medicine and natural science) and does not acknowledge patients’ resources and abilities to be experts in their own lives based on their lived experiences. Improving healthcare safety, quality, and coordination, as well as quality of life, is an important aim in the care of patients with chronic conditions. Person-centered care needs to ensure that people’s values and preferences guide clinical decisions. This paper reviews current knowledge to develop digital care pathways for rhinitis and asthma multimorbidity and digitally enabled, person-centered care.1 It combines all relevant research evidence, including the so-called real-world evidence, with the ultimate goal to develop digitally enabled, patient-centered care. The paper includes Allergic Rhinitis and its Impact on Asthma (ARIA), a 2-decade journey, Grading of Recommendations, Assessment, Development and Evaluation (GRADE), the evidence-based model of guidelines in airway diseases, mHealth impact on airway diseases, .From guidelines to digital care pathways, Embedding Planetary Health, Novel classification of rhinitis and asthma, Embedding real-life data with population-based studies, The ARIA-EAACI (European Academy of Allergy and Clinical Immunology) strategy for the management of airway diseases using digital biomarkers, Artificial intelligence, The development of digitally enabled, ARIA person-centered care, and The political agenda. The ultimate goal is to propose ARIA 2024 guidelines centered around the patient to make them more applicable and sustainable.
- Adherence to treatment in allergic rhinitis during the pollen season in Europe: A MASK‐air StudyPublication . Bousquet, Jean; Amaral, RitaAdherence to rhinitis treatment has been insufficiently assessed. We aimed to use data from the MASK-airmHealth app to assess adherence to oral antihistamines (OAH), intra-nasal corticosteroids (INCS) or azelastine-fluticasone inpatients with allergic rhinitis. We included regular European MASK-air users with self-reported allergic rhinitis and reporting at least 1 day of OAH,INCS or azelastine-fluticasone. We assessed weeks during which patients answered the MASK-air questionnaire on all days. Werestricted our analyses to data provided between January and June, to encompass the pollen seasons across the different assessedcountries. We analysed symptoms using visual analogue scales (VASs) and the combined symptom-medication score (CSMS),performing stratified analyses by weekly adherence levels. Medication adherence was computed as the proportion of days inwhich patients reported rhinitis medication use. Sensitivity analyses were performed considering all weeks with at most 1 day ofmissing data and all months with at most 4 days of missing data. We assessed 8212 complete weeks (1361 users). Adherence (use of medication > 80% days) to specific drug classesranged from 31.7% weeks for azelastine-fluticasone to 38.5% weeks for OAH. Similar adherence to rhinitis medication was foundin users with or without self-reported asthma, except for INCS (better adherence in asthma patients). VAS and CSMS levelsincreased from no adherence to full adherence, except for INCS. A higher proportion of days with uncontrolled symptoms was observed in weeks with higher adherence. In full adherence weeks, 41.2% days reported rhinitis co-medication. The sensitivityanalyses displayed similar results. A high adherence was found in patients reporting regular use of MASK-air. Different adherence patterns werefound for INCS compared to OAH or azelastine-fluticasone that are likely to impact guidelines.
- Symptoms of anxiety and depression in patients with persistent asthma: a cross-sectional analysis of the INSPIRERS studiesPublication . Cunha, Mafalda Simões; Amaral, Rita; Pereira, Ana Margarida; Almeida, Rute; Alves-Correia, Magna; Loureiro, Cláudia Chaves; Lopes, Cristina; Carvalho, Joana; Ribeiro, Carmelita; Vidal, Carmen; Antolín-Amérigo, Dario; Pinto, Diana; Ferreira-Magalhães, Manuel; Vasconcelos, Maria João; Lozoya, Carlos; Santos, Natacha; Cardia, Francisca; Taborda-Barata, Luís; Ferreira, Rosário; Silva, Pedro Morais; Ferreira, Tania Monteiro; Câmara, Raquel; Silva, Eurico; Bordalo, Diana; Guimarães, Cristina; Calix, Maria José; Silva, Sofia da; Marques, Maria Luís; Morete, Ana; Nunes, Carlos; Vieira, Cláudia; Páscoa, Rosália; Alves, Adelaide; Marques, José Varanda; Reis, Bruno; Monteiro, Luís; Monteiro, Rosário; Cepa, Margarida; Valentim, Bruno; Coelho, Daniela Sousa; Fernandes, Sara; Meireles, Patrícia; Aguiar, Margarida Abreu; Mourão, Ana Rita; Fonseca, João A; Jácome, CristinaAnxiety and depression are relevant comorbidities in asthma, but, in Portugal and Spain, data on this topic are scarce. We assessed, in patients with asthma, the frequency of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS) and the European Quality of Life Five Dimension Questionnaire (EQ-5D); the level of agreement between these questionnaires, and the factors associated with these symptoms. This is a secondary analysis of the INSPIRERS studies. A total of 614 adolescents and adults with persistent asthma (32.6±16.9 years, 64.7% female) were recruited from 30 primary care centres and 32 allergy, pulmonology and paediatric clinics. Demographic and clinical characteristics, HADS and EQ-5D were collected. A score ≥8 on Hospital Anxiety and Depression Scale-Anxiety/Hospital Anxiety and Depression Scale-Depression or a positive answer to EQ-5D item 5 indicated the presence of these symptoms. Agreement was determined by Cohen’s kappa. Two multivariable logistic regressions were built. According to HADS, 36% of the participants had symptoms of anxiety and 12% of depression. According to EQ-5D, 36% of the participants had anxiety/depression. The agreement between questionnaires in identifying anxiety/depression was moderate (k=0.55, 95% CI 0.48 to 0.62). Late asthma diagnosis, comorbidities and female gender were predictors of anxiety/depression, while better asthma control, health-related quality of life and perception of health were associated with lower odds for anxiety/depression. At least 1/3 of the patients with persistent asthma experience symptoms of anxiety/depression, showing the relevance of screening these disorders in patients with asthma. EQ-5D and HADS questionnaires showed a moderate agreement in the identification of anxiety/depression symptoms. The identified associated factors need to be further investigated in long-term studies.
- Development and validation of a digital image processing-based pill detection tool for an oral medication self-monitoring systemPublication . Holtkötter, Jannis; Amaral, Rita; Almeida, Rute; Jácome, Cristina; Cardoso, Ricardo; Pereira, Ana; Pereira, Mariana; Chon, Ki H.; Fonseca, João AlmeidaLong-term adherence to medication is of critical importance for the successful management of chronic diseases. Objective tools to track oral medication adherence are either lacking, expensive, difficult to access, or require additional equipment. To improve medication adherence, cheap and easily accessible objective tools able to track compliance levels are necessary. A tool to monitor pill intake that can be implemented in mobile health solutions without the need for additional devices was developed. We propose a pill intake detection tool that uses digital image processing to analyze images of a blister to detect the presence of pills. The tool uses the Circular Hough Transform as a feature extraction technique and is therefore primarily useful for the detection of pills with a round shape. This pill detection tool is composed of two steps. First, the registration of a full blister and storing of reference values in a local database. Second, the detection and classification of taken and remaining pills in similar blisters, to determine the actual number of untaken pills. In the registration of round pills in full blisters, 100% of pills in gray blisters or blisters with a transparent cover were successfully detected. In the counting of untaken pills in partially opened blisters, 95.2% of remaining and 95.1% of taken pills were detected in gray blisters, while 88.2% of remaining and 80.8% of taken pills were detected in blisters with a transparent cover. The proposed tool provides promising results for the detection of round pills. However, the classification of taken and remaining pills needs to be further improved, in particular for the detection of pills with non-oval shapes.