Adaptation of a difficult-to-manage asthma programme for implementation in the Dutch context: a modified e-Delphi

Patients with difficult-to-manage asthma represent a heterogeneous subgroup of asthma patients who require extensive assessment and tailored management. The International Primary Care Respiratory Group approach emphasises the importance of differentiating patients with asthma that is difficult to manage from those with severe disease. Local adaptation of this approach, however, is required to ensure an appropriate strategy for implementation in the Dutch context. We used a modified three-round e-Delphi approach to assess the opinion of all relevant stakeholders (general practitioners, pulmonologists, practice nurses, pulmonary nurses and people with asthma). In the first round, the participants were asked to provide potentially relevant items for a difficult-to-manage asthma programme, which resulted in 67 items. In the second round, we asked participants to rate the relevance of specific items on a seven-point Likert scale, and 46 items were selected as relevant. In the third round, the selected items were categorised and items were ranked within the categories according to relevance. Finally, we created the alphabet acronym for the categories ‘the A–I of difficult-to-manage asthma’ to resonate with an established Dutch ‘A–E acronym for determining asthma control’. This should facilitate implementation of this programme within the existing structure of educational material on asthma and chronic obstructive pulmonary disease (COPD) in primary care, with potential for improving management of difficult-to-manage asthma. Other countries could use a similar approach to create a locally adapted version of such a programme. Difficult-to-manage asthma: A country-specific approach to management A programme to help doctors and patients control difficult-to-manage asthma has been adapted for local use in the Netherlands. It is important to distinguish between truly severe asthma (about 4% of Dutch patients) and so-called difficult-to-manage asthma (about 17%) so that expensive life-saving treatments can be allocated effectively. Persijn Honkoop at Leiden University and co-workers have adapted an internationally-recognised plan, first developed in the UK, for the specific context of the Netherlands. The researchers surveyed professionals and patients, asking them to suggest and rank items they deemed important for a difficult-to-manage asthma programme. The participants generally agreed that patient-specific and behavioural factors were crucial to good diagnosis and