ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle

TLDR: The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

Abstract: The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA-disseminated and implemented in over 70 countries globally-is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

Full text

Bousquet
et al. Clin Transl Allergy (2016) 6:47
DOI 10.1186/s13601-016-0137-4
REVIEW
ARIA 2016: Care pathways implementing
emerging technologies forpredictive medicine
inrhinitis andasthma acrossthe life cycle
J. Bousquet
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© The Author(s) 2016. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
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Open Access
Clinical and
Translational Allergy
*Correspondence: jean.bousquet@orange.fr
^
Deceased
312
CHRU Arnaud de Villeneuve, 371 Avenue du Doyen Gaston Giraud,
34295 Montpellier Cedex 5, France
Full list of author information is available at the end of the article

Page 2 of 14
Bousquet
et al. Clin Transl Allergy (2016) 6:47
Abstract
The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization
workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept
of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used glob-
ally for all countries and populations. ARIA—disseminated and implemented in over 70 countries globally—is now
focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA
(Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop
care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves.
An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symp-
tom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable
tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the
European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an
active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health
and social inequalities incurred by the disease.
Keywords: ARIA, Rhinitis, ICT, EIP on AHA, Mobile technology, AIRWAYS ICPs
J. Millot-Keurinck
218
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R. Nadif
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69,70,71,72
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G. Vezzani
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Background
e Allergic Rhinitis and its Impact on Asthma (ARIA)
initiative commenced during a World Health Organiza
-
tion (WHO) workshop in 1999 (published in 2001) [
1].
e goals were (1) to propose a new allergic rhinitis (AR)
classification using persistence and severity of symp
-
toms in order to more closely reflect patients’ needs, (2)
to promote the concept of multi-morbidity in asthma
and rhinitis as a key factor for patient management, (3)
to develop guidelines with all stakeholders, (4) to include
experts from developed and developing countries and (5)
to initiate global implementation among health care pro
-
fessionals (HCPs) and patients.
Patients, clinicians and other HCPs are confronted
with various treatment choices for the management of
AR. is contributes to considerable variation in clinical
practice. Worldwide, patients, clinicians and other HCPs
are faced with uncertainty about the relative merits and
downsides of the many AR treatment options available.
e first ARIA workshop report used the Shekelle evi
-
dence-based methodology [
1, 2]. It was the first guideline
in chronic disease to assess multi-morbid conditions (i.e.
asthma and rhinitis in the same patient). In 2008, ARIA
was updated using the same evidence-based system [
3].
More transparent reporting of guidelines to facilitate
understanding and acceptance was needed. In its 2010

Page 3 of 14
Bousquet
et al. Clin Transl Allergy (2016) 6:47
Revision, ARIA was the first chronic respiratory dis-
ease guideline to adopt the GRADE (Grading of Recom-
mendation, Assessment, Development and Evaluation)
approach, an advanced evidence evaluation methodology
[
4–7]. A new revision is pending.
ARIA has been disseminated and is implemented in
over 70 countries around the world [
8]. It is now focusing
on the implementation of emerging technologies for indi
-
vidualized and predictive medicine. MASK [MACVIA
(Contre les Maladies Chroniques pour un Vieillissement
Actif)-ARIA Sentinel NetworK] uses mobile technology
to develop care pathways for the management of rhinitis
and asthma by a multi-disciplinary group and by patients
themselves [
9].
e aim of the novel ARIA approach is to provide an
active and healthy life to rhinitis sufferers, whatever their
age, sex or socio-economic status in order to reduce
health and social inequalities incurred by the disease.
AIRWAYS ICPs: the ARIA 2016 political agenda
In 2012, the European Commission launched the Euro-
pean Innovation Partnership on Active and Healthy
Ageing (EIP on AHA; DG Santé and DG CONNECT)
to enhance EU competitiveness and tackle societal chal
-
lenges through research and innovation [
10]. e B3
Action Plan is devoted to the scaling up and replica
-
tion of successful innovative integrated care models for
chronic diseases amongst older patients.
Chronic respiratory diseases were selected to be the
pilot for chronic diseases of the EIP on AHA Action Plan
B3 (Integrated care pathways for airway diseases, AIR
-
WAYS ICPs) [
11, 12] with a life cycle approach [13]. Sev-
eral effective plans exist in Europe for chronic respiratory
diseases, but they are rarely deployed to other regions or
countries.
AIRWAYS ICPs aims to launch a collaboration to
develop practical multi-sectoral care pathways (i.e. ICPs)
in European countries and regions to reduce chronic res
-
piratory disease burden, mortality and multi-morbidity,
while maintaining patients’ quality-of-life (QOL) [
11, 14].
AIRWAYS-ICPs proposes a feasible, achievable and man
-
ageable project (from science to guidelines and policies)
using existing networks. It brings together key stakehold
-
ers including end users, public authorities, industry part-
ners, involved in the innovation cycle, from research to
adoption, as well as those engaged in standardisation and
regulation. e Action Plan of AIRWAYS ICPs has been
devised [
11], implemented [14] and scaled up [15].
AIRWAYS ICPs is a GARD (WHO Global Alliance
against Chronic Respiratory Diseases) [
16] research dem
-
onstration project. Its deployment beyond Europe is car-
ried out via GARD.
One AIRWAYS-ICPs activity is the development of
multi-sectoral care pathways for rhinitis and asthma and
their multi-morbidities, implementing emerging technol
-
ogies for predictive medicine across the patient life cycle
[
13].
From guidelines tointegrated care pathways:
MACVIA-ARIA Sentinel NetworK (MASK)
Best practice, guideline andcare pathways
A good or best practice is a technique, method, process,
activity, incentive, or reward believed to be more effective
than any other technique, method, process, etc. when
applied to a particular condition or circumstance. A best
practice can be adopted as a standard process or be used
as a guideline (U.S. Dept. of Veterans Affairs [
17]).
A guideline is a statement to determine a course of
action. It aims to streamline particular processes accord
-
ing to a set routine or sound practice. By definition, fol-
lowing a guideline is never mandatory. Guidelines are
not binding and are not enforced (U.S. Dept. of Veterans
Affairs [
17]).
“Clinical practice guidelines are systematically devel
-
oped statements to assist practitioner and patient deci-
sions about appropriate health care for specific clinical
circumstances” (Institute of Medicine, 1990). ese clini
-
cal practice guidelines define the role of specific diag-
nostic and treatment modalities. e statements include
recommendations based on evidence intended to help
HCPs and providers in their practice [
18].
e Integrated Care Pathway (ICP) concept was initi
-
ated in 1985 by Zander and Bower [
19]. ICPs are struc-
tured multi-disciplinary care plans detailing key steps of
patient care for a given clinical problem [
20]. ey pro
-
mote the translation of guidelines into local protocols
and their subsequent application to clinical practice. An
ICP forms all or part of the clinical record, documents
the care given, and facilitates the evaluation of out
-
comes for continuous quality improvement [
21]. ey
can help empower patients and their carers (health and
social). ICPs differ from clinical practice guidelines as
they are utilized by a multi-disciplinary team, and focus
on the quality and co-ordination of care. ICPs need to
have a mechanism for recording variations/deviations
from planned care. Like guidelines, an ICP is a guide to
treatment, and clinicians are free to exercise their own
professional judgment as appropriate. However, any
alteration to the practice identified within this ICP must
be noted as a variance [
22]. Variance analysis is a criti
-
cal part of developing and using ICPs [
23]. e resulting
analysis can be used to amend the ICP itself if, for the
majority of patients, the practice is different to the path
-
way (Table
1).

Page 4 of 14
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et al. Clin Transl Allergy (2016) 6:47
Multisectoral care pathways forrhinitis andasthma using
ICT
A large number of AR patients do not consult physi-
cians because they think their AR symptoms are ‘normal’
and/or trivial. However, AR negatively impacts social
life, school and work productivity [
3]. Many AR patients
use over the counter (OTC) drugs [
24] and only a frac
-
tion have had a medical consultation. e vast majority
of patients who visit GPs or specialists have moderate/
severe rhinitis [
25–29]. us, ICPs should consider a
multi-disciplinary approach as proposed by AIRWAYS
ICPs (Fig.
1).
e variations/deviations of the ARIA recommenda
-
tions from planned care have been assessed and several
unmet needs identified. Disease severity is associated
with several health outcomes, including quality of life
[
25–29], and should be considered in ICPs. e dura
-
tion of rhinitis (intermittent/severe-persistent) is an
important indicator of asthma multi-morbidity (in some
but not all studies) [
30], duration of AR treatment and
efficacy of treatment in AR [
27]. Most patients receive
combinations of oral antihistamines and intra-nasal cor
-
ticosteroids (INS) [
31–33] which are not evaluated in
guidelines using an appropriate methodology.
Simple approach toassess control inallergic rhinitis
In asthma, the management strategy is based on disease
control, current treatment and future risk (exacerbations,
lung function decline) [
34–36]. In AR, the switch from
symptom severity to disease control to guide treatment
decisions has been led by ARIA and is now expanding to
include MACVIA (a reference site of the EIP on AHA,
EU [
37]) to form an Action Plan (MACVIA-ARIA). New
developments which have facilitated this process include
(1) the introduction of the visual analogue scale (VAS) as
the common validated language of AR control, (2) cat
-
egorization of AR control using VAS score cut-offs, (3)
incorporation of this VAS into simple interactive apps
for both patients (ARIA Allergy Diary) and HCPs (ARIA
Allergy Diary Companion) [
9, 38] and (4) the integration
of all this knowledge into ICPs deployed by the EIP on
AHA [
9].
e VAS represents a simple way of measuring con
-
trol. It has been used in many diseases, including AR.
VAS scores appear to be similar in different countries, for
patients with moderate–severe intermittent or persistent
rhinitis [
39, 40]. An advantage of the VAS is that it can
be used in all age groups, including preschool children
(guardian evaluation) [
41] and the elderly [42, 43]. Fur
-
thermore, it can be used in a wide variety of languages
[
39, 40, 42, 44–48]. VAS scores vary with ARIA AR clas
-
sification in many languages [
28, 44, 49, 50]. A VAS score
of 50/100 mm suggests moderate–severe AR [32, 51,
52], although in some studies this cut-off was >60 mm
[
45]. e VAS has been used to define severe chronic
upper airway disease (SCUAD [
53]). e minimal clini
-
cally important difference (MCID) during treatment was
found to be 2.3/10cm in the French population [
54] and
may be generalized to other countries, but future studies
may refine this cut-off score. VAS score changes appear
to encompass both symptoms and disease-specific QOL
[
54, 55].
As is the case for asthma, the best control of AR should
be achieved as early as possible in order to (1) improve
patient satisfaction and concordance with treatment and
(2) reduce the AR burden including symptoms, reduced
QoL, and school and work presenteeism/absenteeism.
Untreated AR can impair driving ability and put patients
at risk [
56]. e ultimate goal of AR control is to reduce
the direct and indirect costs incurred by AR [
57–60].
e variability in approaches to achieve disease control
is challenging, and necessitates careful monitoring as well
as the step up/step down of individualized therapeutic
regimens over time. However, the challenges of managing
AR are increased by the fact that patients do not often
recognise their AR symptoms or confuse them with those
of asthma or other multimorbidities such as rhinosinusi
-
tis [
61]. erefore, it is important for patients, caregivers
or HCPs to be able to use an AR symptom scoring system
that is simple to use and rapidly responsive to change.
e aim is to encourage effective cross communica
-
tion and achieve rapid and sustained disease control.
MACVIA-ARIA has produced a simple VAS-based algo
-
rithm called the ARIA Clinical Decision Support System
(CDSS) using a VAS score to guide treatment decisions
in a step-up/step-down approach. is CDSS provides
an individualized approach to AR pharmacotherapy
(depending on medication availability and resources)
[
62]. is approach holds the potential for optimal AR
control while minimizing side effects and costs.
MASK (MACVIA-ARIA Sentinel NetworK): rhinitis
andasthma
MASK-rhinitis and asthma is a simple ICT tool used to
implement ICPs for AR and asthma by means of a com
-
mon language (for patients and HCPs) and a CDSS.
Disease control is assessed by VAS, incorporated into
apps for patients (ARIA Allergy Diary) and HCPs (ARIA
Allergy Diary Companion), with the utility to assess
patient QoL (weekly EQ-5D) [
63, 64] and school/work
productivity (weekly WPAI-AS and daily VAS) [
25, 65,
66].
MASK-rhinitis and asthma will (1) allow patients and
caregivers to screen for AR and asthma, and track their
AR control (2) guide pharmacists in the prescription of
OTC medications and referral of patients to physicians

Page 5 of 14
Bousquet
et al. Clin Transl Allergy (2016) 6:47
Table 1 Denition ofguidelines, practice protocols andICPs. Adapted from http://www.implementationcentral.com/guidelines_8.html
Guideline Clinical practice guidelines Care pathway
Focus Specific clinical circumstances Treatment and/or prevention The quality and co-ordination of care
Definition Systematically developed statements to help practitioners
and patients make decisions about appropriate health
care
A suggested course of treatment and/or treatment service
for a specific diagnosis, functional deficit or problem area
Structured, multi-disciplinary plans of care
Goals Makes specific recommendations on health care and links
these to research evidence
Highlights major therapeutic or preventive interventions
Identifies choices of different courses or paths of treatment
Supports the implementation of clinical guidelines and
protocols
Outputs Provides a summary and appraisal of the best available
research evidence or expert consensus
Highlights the strength of the evidence underlying each
recommendation
Describes barriers and facilitators for each recommendation
Provides a logical flow of interventions. Provides detailed
recommendations that build on those made in SPCs
guidelines
Provides detailed guidance for each stage in the manage-
ment of a patient and key performance indicators
Users Clinicians, patients and third parties (all stakeholders
involved)
Specific to clinicians A multidisciplinary clinical team
Components (1) Appraisal of literature (research evidence or expert
consensus)
(2) Summary of recommendations
(3) An outline of how guidelines should be implemented
and how adherence monitored
List of major therapeutic or preventive interventions
Goals: When interventions should be achieved
Options for different choices of treatment and/or preven-
tion
(1) Timeline
(2) Categories of care/intervention
(3) Intermediate and long term outcome criteria
(4) A variance record