J Bousquet

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C Bachert

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L P Boulet

A Bourdin

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P J Bousquet

C E Brightling

A Briggs

J Brozek

R Buhl

A Bush

D Caimmi

M Calderon

P Calverley

P A Camargos

T Camuzat

G W Canonica

K H Carlsen

T B Casale

M Cazzola

A M Cepeda Sarabia

A Cesario

Y Z Chen

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N H Chavannes

R Chiron

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K F Chung

L Cox

G Crooks

M G Crooks

A A Cruz

A Custovic

R Dahl

S E Dahlen

F De Blay

T Dedeu

D Deleanu

P Demoly

P Devillier

A Didier

A T Dinh-Xuan

R Djukanovic

D Dokic

H Douagui

R Dubakiene

S Eglin

F Elliot

R Emuzyte

L Fabbri

A Fink Wagner

M Fletcher

W J Fokkens

J Fonseca

A Franco

P Frith

A Furber

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J Heinrich

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J Hooper

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G Iaccarino

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C Jeandel

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E Valovirta

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J Vestbo

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Integrated care pathways for airway diseases (AIRWAYS-ICPs) European Innovation Partnership on Active and Healthy Ageing, Action Plan B3 Mechanisms of the Development of Allergy (MeDALL, WP10) GARD (Global Alliance against Chronic Respiratory Diseases, WHO) research demonstration project

The objective of Integrated Care Pathways for Airway Diseases (AIRWAYS-ICPs) is to launch a collaboration to develop multi-sectoral care pathways for chronic respiratory diseases in European countries and regions. AIRWAYS-ICPs has strategic relevance to the European Union Health Strategy and will add value to existing public health knowledge by: 1) proposing a common framework of care pathways for chronic respiratory diseases, which will facilitate comparability and trans-national initiatives; 2) informing cost-effective policy development, strengthening in particular those on smoking and environmental exposure; 3) aiding risk stratification in chronic disease patients, using a common strategy; 4) having a significant impact on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long-term (healthy ageing); 5) proposing a common simulation tool to assist physicians; and 6) ultimately reducing the healthcare burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life. In the longer term, the incidence of disease may be reduced by innovative prevention strategies. AIRWAYS-ICPs was initiated by Area 5 of the Action Plan B3 of the European Innovation Partnership on Active and Healthy Ageing. All stakeholders are involved (health and social care, patients, and policy makers). @ERSpublications AIRWAYS-ICPs: launch of a collaboration to develop multi-sectoral integrated care pathways for respiratory disease

Introduction

Chronic respiratory diseases: from guidelines to policies Chronic respiratory diseases are major non-communicable diseases [START_REF] Bousquet | Global Surveillance, Prevention and Control of Chronic Respiratory Diseases. A Comprehensive Approach. Global Alliance against Chronic Respiratory Diseases[END_REF]. Asthma and allergic diseases occur throughout the life cycle and can begin during pregnancy and childhood. In Europe, they affect 30 million children and adults under 45 years of age. Chronic obstructive pulmonary disease (COPD) has an estimated annual death rate of over 4 million people globally. Among the European Union (EU) member states, asthma accounted for an average of 53 hospital admissions per 100 000 population in 2009, and the average COPD-related admission rate was 184 [START_REF]European Lung White Book. 2nd Edn[END_REF]. The annual direct and indirect costs in the 28 EU countries due to COPD or asthma are estimated at J48 billion and J34 billion, respectively [START_REF]European Lung White Book. 2nd Edn[END_REF]. Chronic respiratory diseases affect active and healthy ageing. Asthma in children or adults is a common risk factor for COPD in adults [START_REF] Svanes | Early life origins of chronic obstructive pulmonary disease[END_REF][START_REF] Perret | The interplay between the effects of lifetime asthma, smoking, and atopy on fixed airflow obstruction in middle age[END_REF].

Guidelines for COPD [START_REF] Qaseem | Diagnosis and management of stable chronic obstructive pulmonary disease: a clinical practice guideline update from the American College of Physicians, American College of Chest Physicians, American Thoracic Society, and European Respiratory Society[END_REF] and rhinitis-asthma comorbidity [START_REF] Brozek | Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines: 2010 revision[END_REF] exist using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach [START_REF] Guyatt | GRADE: an emerging consensus on rating quality of evidence and strength of recommendations[END_REF][START_REF] Brozek | Grading quality of evidence and strength of recommendations in clinical practice guidelines part 3 of 3. The GRADE approach to developing recommendations[END_REF]. Global strategies have also been proposed for the prevention and control of asthma [START_REF] Bateman | Global strategy for asthma management and prevention: GINA executive summary[END_REF] and COPD [START_REF] Vestbo | Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: GOLD Executive Summary[END_REF]. However, in older adults, it is often difficult to differentiate between asthma and COPD [START_REF] Gibson | The overlap syndrome of asthma and COPD: what are its features and how important is it?[END_REF], and none of the current guidelines appear to have a specific module for older people [START_REF] Pistelli | Practical management problems of stable chronic obstructive pulmonary disease in the elderly[END_REF].

Effective strategies are needed to reduce chronic respiratory disease burden. National programmes (e.g. the Finnish, Czech or Portuguese asthma or COPD programmes [START_REF] Haahtela | A 10 year asthma programme in Finland: major change for the better[END_REF][START_REF] Kinnula | The 10-year COPD Programme in Finland: effects on quality of diagnosis, smoking, prevalence, hospital admissions and mortality[END_REF]) can be cost-effective [START_REF] Souza-Machado | Rapid reduction in hospitalisations after an intervention to manage severe asthma[END_REF], but they are insufficiently implemented in the EU. Integrated care pathways (ICPs) for COPD (QS10) exist in the UK (National Institute for Health and Care Excellence, NICE) [START_REF]Chronic Obstructive Pulmonary Disease: Management of Chronic Obstructive Pulmonary Disease in Adults in Primary and Secondary Care (partial update). London, National Clinical Guideline Centre for Acute and Chronic Conditions[END_REF], in France (Haute Autorite ´de Sante ´) and in the Netherlands [17][START_REF] Alliantie | Zorgstandaard astma Kinderen & Jongeren [Standards of Care for Asthma in Children and Young People[END_REF][START_REF] Alliantie | Zorgstandaard COPD [Standards of Care for COPD[END_REF], but ICPs for asthma or asthma and rhinitis comorbidity do not exist. Asthma quality standards for asthma (QS25) have been published by NICE [START_REF]Asthma. Quality standards[END_REF]. These are specific, concise statements that act as markers of high-quality, cost-effective patient care. Moreover, some initiatives are aimed at also incentivising good practice and improving implementation (i.e. remuneration based on performance indicators). In the UK, the Quality and Outcomes Framework has four asthma-specific performance indicators which are explicitly linked to the subsequent remuneration of providers [21].

In low-resource settings, some successful attempts to combine all non-communicable diseases into one single action plan have been developed [START_REF]World Health Organization. Package of Essential NCD Interventions for Primary Health Care: Cancer, Diabetes, Heart Disease and Stroke, Chronic Respiratory Disease[END_REF][START_REF] Hamzaoui | Practical approach to lung health: lung health for everyone?[END_REF][START_REF] English | Development of a South African integrated syndromic respiratory disease guideline for primary care[END_REF] for the implementation of the World Health Organization (WHO) non-communicable disease action plan. However, such combined plans are not available for the management of non-communicable diseases in high-resource settings.

The Polish Presidency of the EU Council (3051st Council Conclusions) has made the prevention, early diagnosis and treatment of asthma and allergic diseases a priority to reduce health inequalities [START_REF] Samolinski | Council of the European Union conclusions on chronic respiratory diseases in children[END_REF][START_REF] Samolinski | Prevention and control of childhood asthma and allergy in the EU from the public health point of view: Polish Presidency of the European Union[END_REF]. The 3206th Cyprus Council Conclusions recommended that the diagnosis and treatment of chronic diseases should be initiated as early as possible to improve active and healthy ageing [START_REF]Council Conclusions on Healthy Ageing Across the Lifecycle[END_REF]. A debate at the European Parliament (Cyprus Presidency of the EU Council, 2012) recommended early diagnosis and management of chronic respiratory diseases in children in order to promote active and healthy ageing [START_REF] Bousquet | Impact of early diagnosis and control of chronic respiratory diseases on active and healthy ageing. A debate at the European Union Parliament[END_REF].

Protective and risk factors

Chronic respiratory diseases and other non-communicable diseases often share environmental risk factors (e.g. tobacco, nutrition, indoor and outdoor air pollution, and sedentary lifestyle) [START_REF] Bousquet | Global Surveillance, Prevention and Control of Chronic Respiratory Diseases. A Comprehensive Approach. Global Alliance against Chronic Respiratory Diseases[END_REF][START_REF] Bousquet | Systems medicine and integrated care to combat chronic noncommunicable diseases[END_REF], leading to sustained local and systemic inflammation [START_REF] Yanbaeva | Systemic effects of smoking[END_REF][START_REF] Petersen | The anti-inflammatory effect of exercise[END_REF] and impaired ageing. Tobacco smoking is the bestidentified risk factor for many non-communicable diseases, including chronic respiratory disease.

The prevention and control of chronic diseases could be considered sequentially before the disease has been identified in order to 1) prevent its onset (health promotion and primary prevention), and 2) better control and prevent the short-and long-term consequences after its onset (secondary and tertiary prevention and control).

Starting in early childhood, the foundations for healthy or weakened respiratory organs are laid from a political perspective to feed into the goals of the Europe 2020 strategy as well as healthy and active ageing [START_REF]Consultation on the Pilot European Innovation Partnership on Active and Healthy Ageing[END_REF]. Multi-sectoral prevention, including policy change, regulation and market intervention, is of the highest priority.

Integrated care pathways

ICPs, also known as clinical pathways or care pathways, are structured multidisciplinary care plans which detail essential steps in the care of patients with a specific clinical problem [START_REF] Campbell | Integrated care pathways[END_REF]. They promote 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 outcomes for continuous quality improvement [START_REF] Overill | A practical guide to care pathways[END_REF]. ICPs empower patients as well as their health and social carers.

ICPs differ from practice guidelines as they are utilised by a multidisciplinary team, and focus on the quality and co-ordination of care. ICPs need to record variations from planned care [START_REF]Great Ormond Street Hospital for Children NHS Trust. How to Produce and Evaluate an Integrated Care Pathway (ICP): Information for Staff[END_REF]. An ICP is intended to inform and encourage thought and adaptation. Clinicians are free to exert their own professional judgments as appropriate. However, any alteration to the practice identified within the ICP must be noted as a variance [36]. Variance analysis may be used to optimise the ICPs linked with pay-for-performance [START_REF] Campbell | Effects of pay for performance on the quality of primary care in England[END_REF][START_REF] Kirschner | Assessment of a pay-for-performance program in primary care designed by target users[END_REF][START_REF] Rodriguez | The reliability of medical group performance measurement in a single insurer's pay for performance program[END_REF][START_REF] Pinnock | Clinical implications of the Royal College of Physicians three questions in routine asthma care: a real-life validation study[END_REF], audit and feedback, and integration of recommendations with electronic medical records.

ICPs are already the standard of care in different areas of medicine, such as oncology [START_REF] Ouwens | Implementation of integrated care for patients with cancer: a systematic review of interventions and effects[END_REF] or palliative care [START_REF] Chan | End-of-life care pathways for improving outcomes in caring for the dying[END_REF]. Some have already been proposed for asthma or COPD.

The care pathways simulator, a discrete event simulation software programme, helps to view the system from the perspective of the task, job or patient, rather than of the function [START_REF] Doods | Designing improved health care processes using discrete event stimulation[END_REF]. Service redesign, targeted at improving services, can bring benefit to patients, carers, staff and National Health Service (NHS) trusts [START_REF] O'connor | Healthcare professional versus patient goal setting in intermittent allergic rhinitis[END_REF].

European Innovation Partnership on Active and Healthy Ageing

European innovation partnerships attempt to enhance EU competitiveness and to tackle societal challenges by fostering innovation. They address the weaknesses in EU research and innovation that complicate the discovery or exploitation of knowledge and may hinder innovation into the market place.

Active and healthy ageing is a major societal challenge common to all countries and to all populations [START_REF] Lisspers | Riktlinjer for allergisk rinit och astma maste na ut. Primarvarden och de lokala apoteken behover samarbeta mer [Guidelines for allergic rhinitis and asthma must reach out. Primary health care and the local pharmacies need to cooperate more[END_REF]. Ageing is intertwined with socioeconomic inequalities [START_REF] Sullivan | The effect of the Rx-to-OTC switch of loratadine and changes in prescription drug benefits on utilization and cost of therapy[END_REF], is an under-appreciated cause of poverty and hinders economic development, particularly affecting underserved populations and females. Active and healthy ageing needs to be promoted very early in life to be successful.

The European Innovation Partnership on Active and Healthy Ageing (EIP on AHA) is deployed in three areas and six action plans [START_REF]The Specific Actions and How to Engage in their Implementation[END_REF]:

N Prevention of diseases and health promotion N Innovative ways to ensure that patients adhere to their treatments (A1) N Innovative solutions for personalised health management, with focus on falls prevention (A2) N Action for preventing functional decline and frailty, with a particular focus on malnutrition (A3) N Care and cure: scaling up and replication of successful innovative integrated care models for chronic diseases among older patients, such as through remote monitoring (B3) N Active and independent living of older adults by improving the uptake of interoperable independent living solutions including guidelines for business models (C2) N Horizontal topics: networking and knowledge sharing on innovation for age-friendly environments (D4)

The EIP on AHA aims to provide a framework for supporting bottom-up innovations and a forum for professional collaboration. The partners work on a voluntary basis to pool their knowledge and expertise in order to deploy, scale-up and replicate innovative health and care services.

The implementation of the strategy and action plan of WHO Europe on healthy ageing [START_REF]World Health Organization Regional Office for Europe. Strategy and Action Plan for Healthy Ageing in Europe, 2012-2020[END_REF] has synergies with a number of the priorities and actions identified in the strategic implementation plan of the EIP on AHA, and shares its positive vision of ageing.

Objectives of AIRWAYS-ICPs

The general objective of AIRWAYS-ICPs is to develop multi-sectoral ICPs for CRDs used across European countries and regions in order to 1) reduce the burden of the diseases, 2) promote active and healthy ageing, and 3) create a care pathways simulator tool which can be applied in older adults. AIRWAYS-ICPs will not duplicate existing EU prevention programmes in chronic respiratory diseases (e.g. anti-smoking) but will strengthen them where appropriate.

The aim of AIRWAYS-ICPs is to propose central unifying themes and an overall potential to gain political leverage in the current environment and to better understand and manage the spectrum of care for patients with chronic airway disease in European countries and regions. It will also aim to generalise the approach to the uniform definition of severity, control and risk of severe asthma presented to the WHO [START_REF] Bousquet | Uniform definition of asthma severity, control, and exacerbations: document presented for the World Health Organization Consultation on Severe Asthma[END_REF], as well as of allergic diseases [START_REF] Bousquet | Severe chronic allergic (and related) diseases: a uniform approach -a MeDALL-GA2LEN-ARIA position paper[END_REF], in order to develop a uniform risk stratification usable for chronic respiratory diseases in most situations.

AIRWAYS-ICPs will propose a feasible, achievable and manageable project from science to guidelines (fig. 1) using existing networks and partners committed to Action Plan B3 of the EIP on AHA.

Specific objectives include the following:

1) To collect guidelines and ICPs that exist in European countries and regions for airway diseases (asthma, COPD and rhinitis).

2) To strengthen prevention and health promotion for airway diseases.

3) To stratify patients with severe chronic respiratory diseases.

4) To understand AIRWAY diseases in children and adolescents and to develop ICPs (P.A.R.IS).

Outcomes

5)

To develop important questions on chronic respiratory diseases for older people. 6) To understand and overcome barriers in chronic respiratory disease management. 7) To develop ICPs for rhinitis and asthma comorbidity across the life cycle, and for COPD and asthma in older people, combining preventive and disease control strategies based on existing national (or regional) programmes (e.g. Finnish or Portuguese asthma, COPD and allergy programmes). 8) To develop a simulation tool of ICPs for rhinitis and asthma comorbidity that could be applied to older people and to redesigning care pathways. 9) To tackle chronic respiratory diseases across the life cycle, placing a particular interest in the cultural and social aspects of the diseases in a project centred on the patient. 10) To implement multi-sectoral, multi-country initiatives to allow the practical use of AIRWAYS-ICPs by European countries and regions, and beyond to other countries, for cost-effective policies on the prevention and control of asthma, COPD and allergy.

AIRWAYS-ICPs working group

The AIRWAYS-ICPs working group has included the WHO Global Alliance against Chronic Respiratory Diseases and WHO Collaborating Center (2001-2013) working groups (64 countries). Moreover, we have attempted to include as many European countries as possible (23 EU countries) and it should be noted that Serbia, Croatia, Slovenia and Slovakia, who were not included in the previous study groups, are now included with a large number of representatives. Moreover, we have enhanced the study group by including social carers and public health researchers. Patients are well represented. In some countries, the names of the representatives have been proposed by governmental organisations. Finally, through the EIP on AHA, European Regions and Health Authorities (EUREGHA), other representatives were included, in particular NHS England, Scotland and Northern Ireland, as well as Wallonie and Southern Denmark. The working group now includes all the stakeholders required for the development of multi-sectoral ICPs.

AIRWAYS-ICPs 1) To collate existing ICPs, national programmes and guidelines

Tools used in the 28 EU countries and other European countries will be collected with regards to ICPs for COPD, asthma and rhinitis. This approach will be deployed to other countries. A repository is being developed by the EIP on AHA to collect projects such as:

1) Good practices of the B3 Action Group on integrated care.

2) The Finnish plans for asthma [START_REF] Haahtela | A 10 year asthma programme in Finland: major change for the better[END_REF], allergy [START_REF] Haahtela | Finnish Allergy Programme 2008-2018 -time to act and change the course[END_REF] and COPD [START_REF] Kinnula | The 10-year COPD Programme in Finland: effects on quality of diagnosis, smoking, prevalence, hospital admissions and mortality[END_REF] which are considered to be the prototypes of national plans for chronic respiratory diseases. Polastma (Poland) is, in particular, derived from the asthma plan.

3) The Portuguese National Programme for Respiratory Diseases (PNDR), the first national programme to include all respiratory diseases. 4) Care pathways provided by national institutions (e.g. NICE in the UK or the Haute Autorite ´de Sante ´in France).

5) The WHO guidelines for asthma and COPD in low-income settings.

6) A common approach to severe asthma and allergic diseases. 7) International Primary Care Respiratory Group mapping of national guidelines used by primary care for COPD, asthma, rhinitis, community-acquired pneumonia, obstructive sleep apnoea and smoking cessation [START_REF]Mapping of National Guidelines used by Primary Care[END_REF].

2) To strengthen EU policies for the prevention of chronic respiratory diseases

The European Commission addresses chronic respiratory disease as a key priority and includes legislation on tobacco consumption and ambient air quality, work on climate change, and actions under the European Environment and Health Strategy. These policies tie in with active Commission support for the current United Nations process to address non-communicable diseases and related socioeconomic and environmental determinants. There is an urgent need to strengthen prevention and health promotion, in particular for smoking cessation (''Health for Growth'' public health programme), improved physical and social environment, and promotion of lifestyle of beneficial value for ''whole of society'' and ''vulnerable groups'' in particular [START_REF]Council Conclusions: Innovative Approaches for Chronic Diseases in Public Health and Healthcare Systems. 3053rd Employment, Social Policy Health and Consumer Affairs Council Meeting[END_REF].

3) Stratification of patients with severe chronic respiratory diseases Severity is the intrinsic severity of the disease process, control is the degree to which therapy goals are met, and responsiveness is the ease with which control is achieved by therapy. The concept of severity and control has been largely developed for asthma in guidelines [START_REF] Bousquet | GINA guidelines on asthma and beyond[END_REF]. The uniform definition of severe asthma [START_REF] Bel | Diagnosis and definition of severe refractory asthma: an international consensus statement from the Innovative Medicine Initiative (IMI)[END_REF] presented to the WHO [START_REF] Bousquet | Uniform definition of asthma severity, control, and exacerbations: document presented for the World Health Organization Consultation on Severe Asthma[END_REF] used an approach derived from the National Asthma Education and Prevention Program Expert Panel Report 3 guidelines [START_REF]3: Guidelines for the Diagnosis and Management of Asthma[END_REF]. This approach has also been used for all allergic diseases (fig. 2) [START_REF] Bousquet | Severe chronic allergic (and related) diseases: a uniform approach -a MeDALL-GA2LEN-ARIA position paper[END_REF] and may be used for COPD (table 1).

The stratification of patients with chronic respiratory diseases can be generalised using the approach of the uniform definition of severe asthma presented to the WHO [START_REF] Bel | Diagnosis and definition of severe refractory asthma: an international consensus statement from the Innovative Medicine Initiative (IMI)[END_REF], in order to have a uniform definition of severity, control and risk usable in most situations. This uniform definition will make it possible to better define the phenotypes of severe allergic (and related) diseases for clinical practice, research (including epidemiology), public health purposes and the development of novel therapies targeted to better defined phenotypes.

4) Understanding airway diseases in children and adolescents and developing ICPs (P.A.R.IS)

Allergic diseases and asthma often start early in life, and most patients will have developed disease before the age of 18 years. It is therefore important to understand the risk factors and mechanisms underlying allergic chronic respiratory diseases and asthma in childhood, as well as to determine the gaps in the management of these diseases in preschool children, school children and adolescents. The prevention of early diagnosis and the management of chronic respiratory diseases in children is vital for the improvement of active and healthy ageing.

Within the framework of the EIP on AHA, the European Academy of Allergy and Clinical Immunology (EAACI) has decided, in collaboration with Allergic Rhinitis and its Impact on Asthma (ARIA), to develop a programme to better understand AIRWAY diseases in children and to propose a framework for the development of ICPs in this age group, considering rhinitis and asthma as a single entity.

The Allergy Sentinel Network, approved by the European Parliament, will be developed in Paris [START_REF] Bousquet | Impact of early diagnosis and control of chronic respiratory diseases on active and healthy ageing. A debate at the European Union Parliament[END_REF].

5) Development of important questions on chronic respiratory diseases for older people

Clinically important questions on the diagnosis and management of chronic respiratory diseases in older adults will be defined using a three-step Delphi process. The questions include COPD, asthma, rhinitis and chronic respiratory disease comorbidities. Multi-sectoral experts and patients are included. First Delphi round: experts were asked to propose the three major problems they would like to have answered concerning disease in older people, including comorbidities.

Second Delphi round: the questions were assessed by a group of four experts (two methodologists) to check for redundancy among the questions proposed (similar wording).

Third Delphi round: the questions were sent to the group for agreement.

Fourth Delphi round: the harmonised questions will be sent to 60 experts who will rank them.

The prioritised questions include: 1) asthma in older people; 2) COPD in older people; 3) rhinitis in older people; 4) comorbidities of asthma and COPD in older people; and 5) how paediatric interventions have an impact on ageing associated with respiratory diseases.

The list of questions will also be customised in order to be applicable to all countries and targeted to low, middle and high-income settings within which socioeconomic and health problems differ. The third Delphi round will be reviewed by two expert panels: one from developing countries and another from developed countries.

The prioritised questions will be answered after a review of available evidence using the GRADE approach.

Further to the first completed steps, it was felt that a better definition was needed for airway diseases and how they cluster in comorbidities (respiratory and non-respiratory). There are likely to be differences within the life cycle.

6) Understanding and overcoming barriers in chronic respiratory disease management

Many barriers exist and prevent the deployment and use of a non-communicable disease global approach in different settings and countries.

7) Development of ICPs for rhinitis and asthma comorbidity across the life cycle, and for COPD, asthma and comorbidities in older people 1) To develop multi-sectoral ICPs which can be used across Europe and in other countries.

2) For asthma and rhinitis comorbidity, the P.A.R.IS approach (EAACI-ARIA) will be used in children and the ARIA approach in adults and older people.

3) A combined approach to asthma and COPD has been proposed for older people, as the two diseases overlap and are often difficult to differentiate, particularly at the primary care level. Moreover, non-respiratory comorbidities will be included since older patients often have several diseases with poly-pharmacy. 4) To combine strategies for prevention and control.

5)

To place a special emphasis on older and/or underserved patients. 6) To implement cost-effective policies for the prevention of chronic respiratory diseases. 7) To promote active and healthy ageing. AIRWAYS-ICPs places a particular interest in cultural and societal aspects of the diseases in a project centred on the patient. 8) Interactions will take place between several sections of AIRWAYS-ICPs in order to develop ICPs (fig. 3). Health technology assessment will lead to recommendations that will be evaluated in each country (or EU region) in order to develop multi-sectoral ICPs which may differ depending on the differences within the health systems, and on the socioeconomic and political priorities of the different countries. Health costs associated with the long-term care of older people have increased in all countries. Computerbased simulation tools may provide integrated care services to older people. The simulation is used for decision-making in healthcare systems by increasing efficiency and reducing unnecessary cost, while maintaining or improving quality of care [START_REF] Hamrock | Discrete event simulation for healthcare organizations: a tool for decision making[END_REF]. It is linked to the processes of change or reform of the system [START_REF] Bolton | Better than a crystal ball? Using simulation to foresee emerging issues in the Australian Healthcare System[END_REF], and is used as a tool to address the complexity of healthcare systems (healthcare ecosystem) in which all stakeholders interact (patients, managers, policy makers and professionals). Examples are applied to infectious diseases [START_REF] Lee | The Regional Healthcare Ecosystem Analyst (RHEA): a simulation modeling tool to assist infectious disease control in a health system[END_REF]. The simulation allows the identification of treatment effects in longitudinal healthcare data [START_REF] Murray | Design and validation of a data simulation model for longitudinal healthcare data[END_REF], preventing technology-induced errors in healthcare [START_REF] Borycki | Toward an integrated simulation approach for predicting and preventing technology-induced errors in healthcare: implications for healthcare decision-makers[END_REF]. In the area of ''AIRWAYS ICPs'', computational analysis has been used to analyse the role of asthma in airway mechanics parameters [START_REF] Pidaparti | Simulation of the effect of airway disease on respiratory airways[END_REF].

LTCMAS (Long-Term Care Multi-Agent Systems) [START_REF] Grimaldo | Towards a simulator of integrated long-term care systems for elderly people[END_REF] is a simulator that, as a starting point, used a holistic model of care systems for people that need long-term care, the Sustainable Socio-Health Model (SSHM). The implementation of the simulator on the Jason multi-agent platform allows the tool to include human interactions, preferences and social abilities that take place between older people and the staff of healthcare systems (health and social workers). The use of this multi-agent platform provides the required scalability for simulating population sizes of different orders of magnitude. The closed-loop design of the proposed simulator permits repeated simulation of successive interactions of the target population with the healthcare system. The simulator may forecast the long-term effects of different policies on the considered population as well as on the healthcare system.

Using the Spanish simulation tool LTCMAS [START_REF] Grimaldo | Towards a simulator of integrated long-term care systems for elderly people[END_REF] as a prototype, a new version will be adapted to the AIRWAYS patient group (LCT+ AIRWAYS ICPs). LCT+ AIRWAYS ICPs will be available in primary care centres through health information systems to assist physicians in the stratification of patients and choice of pathways, including an attempt to include resource use/cost implications.

9) Tackling chronic respiratory diseases across the life cycle

Pre-natal and early-life events have a major impact on the development of chronic diseases in adults [START_REF] Barker | Fetal and placental size and risk of hypertension in adult life[END_REF][START_REF] Krauss-Etschmann | Of flies, mice and men: a systematic approach to understanding the early life origins of chronic lung disease[END_REF] and older people, including diabetes [START_REF] Simeoni | Offspring of diabetic pregnancy: long-term outcomes[END_REF], coronary heart diseases [START_REF] Barker | Coronary heart disease: a disorder of growth[END_REF], asthma [START_REF] Bousquet | Epigenetic inheritance of fetal genes in allergic asthma[END_REF], COPD [START_REF] Svanes | Early life origins of chronic obstructive pulmonary disease[END_REF] or neurodegenerative diseases [START_REF] Landrigan | Early environmental origins of neurodegenerative disease in later life[END_REF]. A better understanding of these links will make it possible to propose effective novel prevention strategies to promote active and healthy ageing.

The developmental origin of ageing is on the EU political agenda. The Polish Priority of the EU Council (2011) promoted the recognition, prevention and management of chronic respiratory diseases in children to ultimately affect healthy ageing [START_REF] Samolinski | Prevention and control of childhood asthma and allergy in the EU from the public health point of view: Polish Presidency of the European Union[END_REF]. The developmental determinants of non-communicable diseases in ageing were reinforced during the Cyprus Presidency of the EU Council (2012), which proposed to fight against non-communicable diseases across the life cycle [START_REF]Council Conclusions on Healthy Ageing Across the Lifecycle[END_REF]. A meeting at the European Parliament, organised by the Region Languedoc Roussillon and under the auspices of the Cyprus EU Priority (November 2012), was focussed on chronic respiratory diseases [START_REF] Bousquet | Impact of early diagnosis and control of chronic respiratory diseases on active and healthy ageing. A debate at the European Union Parliament[END_REF].

In order to find novel health promotion strategies in non-communicable diseases and to promote value creation, pre-natal and early life events were discussed in a meeting on December 2-3, 2013 by the Region Languedoc Roussillon and under the auspices of the frame of Action B3 of the EIP on AHA.

10) Multi-sectoral, multi-country initiative

Members of each European country will be involved in a multi-sectoral approach: primary and secondary care, healthcare professionals (including pharmacists and nurses), social carers, patients and policy makers. Patients' organisations and major European scientific societies are partners of the WHO Collaborating Centre for Asthma and Rhinitis for this initiative. EUREGHA will help to deploy AIRWAYS-ICPs in the EU regions. Partners outside the EU will also be involved in the initiative. Education and coaching for all stakeholders with patients' organisations will be developed.

Interactions with the private sector have already been established with, as an example, Eurobiomed (www. eurobiomed.org; Commitment for Action B3 Action Plan), the focal point for the economic growth of MACVIA-LR (Contre les Maladies Chroniques pour un Vieillissement Actif; Fighting Chronic Diseases for Active and Healthy Ageing).

Added value

AIRWAYS-ICPs is a demonstration project that follows the recommendations of the EU (Council Conclusions) [START_REF] Samolinski | Council of the European Union conclusions on chronic respiratory diseases in children[END_REF][START_REF] Samolinski | Prevention and control of childhood asthma and allergy in the EU from the public health point of view: Polish Presidency of the European Union[END_REF] and which may be the model for ICPs in other chronic diseases for Action Plan B3 of the EIP on AHA.

The project does not duplicate actions that can be taken at the country level, but rather highlights problems that are not sufficiently addressed, and facilitates or enables rectification of these needs. As an example, fewer than 10 EU countries have a national asthma plan under the auspices of the Ministry of Health. Moreover, in many European regions, although healthcare is delivered by regions, the existence of regional plans is scarce.

AIRWAYS-ICPs will be built using the solutions for chronic respiratory diseases that already exist in countries or regions, as well as with the expertise of health professionals across Europe and beyond. The solutions that have been validated by professionals or that have already evidenced their success will be promoted in order to reduce fragmentation.

This project responds to the 3053rd EU Council conclusions: ''innovative approaches for chronic diseases in public health and healthcare systems'' adopted on December 7, 2010 and to the United Nations High Level meeting (2011). Asthma and allergic diseases are common chronic respiratory diseases and 200 million subjects are affected in Europe. Furthermore, the project uses ICT -innovative simulation tools. It focuses on the conclusions of the 3131st session of the EU Council (2011) on the Prevention and Control of CRDs in Children. Asthma plans are particularly effective in underserved populations and attempts will be undertaken to reduce health inequities.

The project will help to achieve the objective of an active ageing, and responds to the 3206th Council Conclusions [START_REF]Council Conclusions on Healthy Ageing Across the Lifecycle[END_REF] that recommend the initiation of early diagnosis and treatment of chronic diseases as early as possible in order to improve active and healthy ageing.

The aim of AIRWAYS-ICPs is to improve healthy life years and to reduce burden (emergency visits, avoidable hospitalisations, disability and costs) while improving quality of life worldwide, and, in the longer term, to reduce disease incidence by new and innovative prevention strategies.

AIRWAYS-ICPs has a clear strategic relevance with regard to the EU Health Strategy as it will bring added value to the existing public health knowledge:

N To propose a common framework for chronic respiratory disease (and for comorbidities) ICPs for the entire EU which can then be expanded to other regions (e.g. the Commonwealth of Independent States) and which will allow comparability and trans-national initiatives.

N To help risk stratification in chronic respiratory disease patients, using a common strategy. N To develop cost-effective policies, in particular strengthening those on smoking and environment exposure.

N To have a significant implication on the health of citizens in the short term (reduction of morbidity, improvement of education in children and of work in adults) and in the long term (healthy ageing).

N To propose a common simulation tool for the entire EU in order to assist physicians in the segmentation of patients and in the choice of pathways.

FIGURE 2

 2 FIGURE 2Decision-making steps for the stratification of severe allergic disease, with correlating action steps for management. Reproduced from[START_REF] Bousquet | Severe chronic allergic (and related) diseases: a uniform approach -a MeDALL-GA2LEN-ARIA position paper[END_REF] with permission from the publisher.

  INTEGRATED CARE PATHWAYS FOR AIRWAY DISEASES | J. BOUSQUET ET AL.

		Raise new issues and
		level of ambition
		Problem framing and goal setting	Implement best practices
	FIGURE 1 From science to guidelines and best practices.	Evaluate critically and identify causes of failure	Participate in operationalising Collaborate and challenge Address different audiences

DOI: 10.1183/09031936.00014614

TABLE 1

 1 Stratification steps for severe asthma and chronic obstructive pulmonary disease (COPD)

	INTEGRATED CARE PATHWAYS FOR AIRWAY DISEASES | J. BOUSQUET ET AL.
		Asthma	COPD
	Underdiagnosis	Common	Extremely common
		If asthma is not diagnosed, severe exacerbations	Patients usually consult when they have (very)
		can occur	severe disease or an exacerbation
		Asthma deaths mostly occur in untreated patients	If diagnosed earlier, smoking cessation measures
		In occupational asthma, early diagnosis is needed	could be initiated and prevent the worsening of
			COPD and comorbidities
	Effective treatment
	Preventive treatment	Asthma prevention is not effective, except in some	Smoking cessation effective (at least when
		cases, such as occupational asthma	started early)
	Drugs	Inhaled corticosteroids and b 2 -agonists very	Somewhat effective on symptoms
		effective on symptoms and control	High variability due to different COPD phenotypes
		At regular doses, no treatment is clearly effective	(e.g. chronic bronchitis and emphysema)
		on remodelling	Modestly effective on exacerbations, possibly
			because phenotypes are not well characterised
			and COPD encompasses several different
			phenotypes which may respond differently
			to drugs
			No treatment effective on decline of lung function
	Treatment availability and	A global problem
	affordability
	Differential diagnosis	Many ''uncontrolled'' patients with current	Many COPD patients have a differential diagnosis
		asthma medications have asthma and another	(including lung cancer)
		disease or another disease (e.g. bronchiectasis)
	Compliance and literacy	For drugs	For smoking cessation
	Inhaler misuse	A global problem
	Smoking and other risk factors	A global problem
	Comorbidities	Severe nasal problems (e.g. polyposis) may	Key problem: many patients with COPD have
		impair asthma control	severe comorbidities that may not even
			be diagnosed
			Many deaths are due to comorbidities
	Mood, depression and socioeconomic	A global problem
	status
	Controlled disease with high	A large number of patients fall into this category	Phenotypes are not well characterised and COPD
	intensity treatment	If treatment is stopped, exacerbations can	encompasses several different diseases (e.g.
		occur quickly	chronic bronchitis and emphysema) that may
			respond differently to drugs
			Phenotypic characterisation is urgently needed

DOI: 10.1183/09031936.00014614

Eur Respir J 2014; 44: 304-323 | DOI: 10.1183/09031936.00014614

DOI: 10.1183/09031936.00014614

Acknowledgements

The members of the AIRWAYS-ICPs study group are as follows: J. Bousquet (University Hospital Montpellier; MACVIA-LR, Fighting Chronic Diseases for Healthy Ageing, Re ´gion Languedoc Roussillon; MeDALL, Mechanisms of the Development of Allergy; ARIA, Allergic Rhinitis and Its Impact on Asthma; EAACI, European Academy of Allergy and Clinical Immunology; EIP-on-AHA, European Innovation Partnership on Active and Healthy Ageing, Reference Site; EIP-on-AHA, European Innovation Partnership on Active and Healthy Ageing, B3 Commitment for Action; UM1, University 1, Montpellier; and Fondation Partenariale, France), A. Addis (EIP-on-AHA, European Innovation Partnership on Active and Healthy Ageing, Reference Site; EIP-on-AHA, European Innovation Partnership on Active and Healthy Ageing, B3 Commitment for Action, Regione Emilia-Romagna, Italy), I. Adcock (National Heart and Lung Institute, Imperial College London and Royal Brompton and Harefield NIHR Biomedical Research Unit, London, UK), I. Agache (ARIA, Allergic Rhinitis and Its Impact on Asthma; Romanian Alliance against Chronic Respiratory Diseases; Faculty of Medicine, Transylvania University, Brasov, Romania), A. Agusti (Thorax Institute, Hospital Clinic, IDIBAPS, University of Barcelona and CIBER Enfermedades Respiratorias, Spain), N. Aı ¨t-Khaled (The Union), R. Akdag ˘(Global Alliance against Chronic Respiratory Diseases (GARD), Turkey), C.A. Akdis (SIAF, Swiss Institute of Allergy and Asthma Research and University of Zurich; and Christine Ku ¨hne -Center for Allergy Research and Education, Davos, Switzerland), M. Akdis (SIAF, Swiss Institute of Allergy and Asthma Research and University of Zurich, Switzerland), A. Alonso (Hospital Clı ´nic/FCRB, Barcelona, Spain), P. Altan (Global Alliance against Chronic Respiratory Diseases (GARD), Turkey), T. Altunsu (Global Alliance against Chronic Respiratory Diseases (GARD), Turkey), C. Andersen (APFQ, Associac ¸a ˜o Portuguesa de Fibrose Quı ´stica), A. Andrianarisoa (SPLF, Espace francophone de Pneumologie), I. Annesi-Maesano (ARIA, Allergic Rhinitis and Its Impact on Asthma), I.J. Ansotegui (ARIA, Allergic Rhinitis and Its Impact on Asthma), J.M. Anto (MeDALL, Mechanisms of the Development of Allergy; Centre for Research in Environmental Epidemiology (CREAL); IMIM (Hospital del Mar Medical Research Institute); Universitat Pompeu Fabra (UPF); and CIBER Epidemiologı ´a y Salud Pu ´blica (CIBERESP), Barcelona, Spain), L. Araujo (Porto Age-Up consortium; APA, Associac ¸a ˜o Portuguesa de Asma ´ticos, Portugal), T. de Araujo (FPP, Fundac ¸a ˜o Portuguesa do Pulma ˜o), A. Arias Cruz (Colegio Mexicano de Inmunologı ´a Clı ´nica y Alergia; SLaai, Sociedad Latinoamericana de Allergia, Asma e Immunologia), N. Arpacı (Global Alliance against Chronic Respiratory Diseases (GARD), Turkey), A. Arrobas (PNDR, INTEGRATED CARE PATHWAYS FOR AIRWAY DISEASES | J. BOUSQUET ET AL. DOI: 10.1183/09031936.00014614

and Education Center of the Capital Institute of Pediatrics, Peking and Center for Asthma Research and Education, Beijing, PR China), R. Chiron (University Hospital Montpellier; MACVIA-LR, Fighting Chronic Diseases for Healthy Ageing, Re ´gion Languedoc Roussillon, France; ARIA, Allergic Rhinitis and Its Impact on Asthma), E. Chkhartishvili (Chachava Clinic, David Tvildiani Medical University-AIETI Medical School, Gr. Robakidze University, Georgia), A. Chuchalin (ARIA, Allergic Rhinitis and Its Impact on Asthma; GARD, Global Alliance against chronic Respiratory Diseases (WHO); Pulmonology Research Institute and Russian Respiratory Society, Moscow, Russia), K.F. Chung (National Heart and Lung Institute, Imperial College London and Royal Brompton and Harefield NIHR Biomedical Research Unit, London, UK), S.C. Coban (Global Alliance against Chronic Respiratory Diseases (GARD), Turkey), J. Correia de Sousa (APMGF, Associac ¸a ˜o Portuguesa de Medicina Geral e Familiar (APMGF)/Nu ´cleo de Doenc ¸as Respirato ´rias -GRESP), D.J. Costa (MACVIA-LR, Fighting Chronic Diseases for Healthy Ageing, Re ´gion Languedoc Roussillon, France), L. Cox (ARIA, Allergic Rhinitis and Its Impact on Asthma; Nova Southeastern University Osteopathic College of Medicine, Davie, FL, USA), G. Crooks (EIP-on-AHA, European Innovation Partnership on Active and Healthy Ageing, Reference Site; NHS Scotland, Glasgow, UK), M.G. Crooks (Centre for Cardiovascular and Metabolic Research, Hull York Medical School, UK), A.A. Cruz (ARIA, Allergic Rhinitis and Its Impact on Asthma; GARD, Global Alliance against chronic Respiratory Diseases (WHO); ProAR, Nucleo de Excelencia em Asma, Federal University of Bahia and CNPq, Salvador, Brazil), A. Custovic (ARIA, Allergic Rhinitis and Its Impact on Asthma; EAACI, European Academy of Allergy and Clinical Immunology; University of Manchester, Manchester, UK), E. Czarnobilska (Polish Alliance against Chronic Respiratory Diseases), U. Czechowska (Polish Alliance against Chronic Respiratory Diseases), R. Dahl (ARIA, Allergic Rhinitis and Its Impact on Asthma; Dept of Dermatology and Allergy Center, Odense Research Center for Anaphylaxis, Odense University Hospital, Denmark), P. Da ˛browiecki (Polish Alliance against Chronic Respiratory Diseases), S.E. Dahlen (CfA, The Centre for Allergy Research, The Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden), M. David (MACVIA-LR, Fighting Chronic Diseases for Healthy Ageing, Re ´gion Languedoc Roussillon, France), F. De Blay (ARIA, Allergic Rhinitis and Its Impact on Asthma; SFA, Socie ´te ´franc ¸aise d'Allergologie; Strasbourg University, France), T. Dedeu (EUREGHA, European Regions and Health Authorities, Brussels, Belgium), D. Deleanu (ARIA, Allergic Rhinitis and Its Impact on Asthma; Romanian Alliance against chronic respiratory diseases; University of Medicine and Pharmacy Iuliu Hatieganu, Cluj-Napoca, Romania), P. Demoly (University Hospital Montpellier; MACVIA-LR, Fighting Chronic Diseases for Healthy Ageing, Re ´gion Languedoc Roussillon; ARIA, Allergic Rhinitis and Its Impact on Asthma; EAACI, European Academy of Allergy and Clinical Immunology; EIP-on-AHA, European Innovation Partnership on Active and Healthy Ageing, B3 Commitment for Action; and UM1, University 1, Montpellier, France), P. Devillier (ARIA, Allergic Rhinitis and Its Impact on Asthma; UPRES EA 220, Universite ´Versailles Saint Quentin, Ho ˆpital Foch, Suresnes, France

), T. Didi (SPLF, Espace francophone de Pneumologie), A. Didier (SPLF, Socie ´te ´de Pneumologie de Langue Franc ¸aise; Dept of Respiratory Medicine, University of Toulouse, France), S. Dimic ´-Janjic ´(Association for Asthma and COPD in Serbia; Clinic for Pulmonary Diseases, Clinical Centre of Serbia, Serbia), A.T. Dinh Xuan (Service de Physiologie, Paris Descartes University EA 2511, Ho ˆpital Cochin, Assistance Publique Ho ˆpitaux de Paris, France), R. Djukanovic (University Southampton Faculty of Medicine and NIHR Southampton Respiratory Biomedical Research Unit, UK), A. Doboszyn ´ska (Polish Alliance against Chronic Respiratory Diseases), D. Dokic (ARIA, Allergic Rhinitis and Its Impact on Asthma; University Clinic of Pulmology and Allergy, University ''Ss. Cyril and Methodius'', Skopje, Macedonia), H. Douagui (ARIA, Allergic Rhinitis and Its Impact on Asthma; Service de pneumo-allergologie, Centre Hospitalo-Universitaire de Be ´ni-Messous, Algiers, Algeria), R. Dubakiene (ARIA, Allergic Rhinitis and Its Impact on Asthma; LSACI, Lithuanian Society of Allergology University Faculty of Medicine, Lithuania; Vilnius University Faculty of Medicine, Lithuania), A. Dudvarski-Ilic (Faculty of Medicine, University of Belgrade, Serbia; Association for Asthma and COPD in Serbia; and Clinic for Pulmonary Diseases, Clinical Centre of Serbia, Serbia), A. Dymek (Polish Alliance against Chronic Respiratory Diseases), S. Eglin (NHS R&D North West, Faculty of Health and Life Sciences, University of Liverpool, UK), A. El-Meziane (SPLF, Espace francophone de Pneumologie), F. Elliot (EIP-on-AHA, European Innovation Partnership on Active and Healthy Ageing, Reference Site; NHS Scotland, Edinburgh, UK), R. Emuzyte (ARIA, Allergic Rhinitis and Its Impact on Asthma; LSACI, Lithuanian Society of Allergology University Faculty of Medicine, Lithuania; Vilnius University Faculty of Medicine, Lithuania), P. Ergu ¨n (Global Alliance against Chronic Respiratory Diseases (GARD), Turkey), L. Fabbri (Regione Emilia-Romagna, Italy; Dept of Oncology, Haematology and Respiratory Diseases, Policlinic of Modena, University of Modena and Reggio Emilia, Modena, Italy), A.M. Fal (Polish Alliance against Chronic Respiratory Diseases), A. Fink Wagner (GAAPP, Global Allergy and Asthma Patient Platform, Vienna, Austria), M. Fletcher (GARD, Global Alliance against chronic Respiratory Diseases (WHO); Education for Health, Warwick, UK), W.J. Fokkens (ARIA, Allergic Rhinitis and Its Impact on Asthma; Academic Medical Centre, University of Amsterdam, the Netherlands; European Rhinology Society), J. Fonseca (ARIA, Allergic Rhinitis and Its Impact on Asthma; Porto Age-Up consortium, Portugal; PNDR, Portuguese National Programme for Respiratory Diseases; Dept of Health Information and Decision Sciences and CINTESIS, Porto University Medical School; Allergy, Hospital S. Joao and Instituto and Hospital CUF Porto, Portugal), A. Franco (Internal and Geriatric Medicine, University of Nice -Sophia Antipolis, France), P. Frith (Repatriation General Hospital, Adelaide, Australia), A. Furber (Director of Public Health, Wakefield Council, UK), M. Gaga (7th Resp. Med. Dept and Asthma Centre; and Athens Chest Hospital, Athens, Greece), A. Gamkrelidze (ARIA, Allergic Rhinitis and Its Impact on Asthma; National Center for Disease Control and Public Health of Georgia), J. Garce ´s (EIP-on-AHA, European Innovation Partnership on Active and Healthy Ageing, Reference Site; Polibienestar Research Institute, University of Valencia, Spain), J. Garcia-Aymerich (MeDALL, Mechanisms of the Development of Allergy; Centre for Research in Environmental Epidemiology (CREAL); IMIM (Hospital del Mar Medical Research Institute); Universitat Pompeu Fabra (UPF); CIBER Epidemiologı ´a y Salud Pu ´blica (CIBERESP), Barcelona, Spain), G. Ga ˛szczyk (Polish Alliance against Chronic Respiratory Diseases), J.E. Gereda (Allergy and Immunology Division, Clinica Ricardo Palma, Lima, Peru), R. Gerth van Wijk (ARIA, Allergic Rhinitis and Its Impact on Asthma; Section of Allergology, Dept of Internal Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands), E. Go ¨ktas ¸(Global Alliance against Chronic Respiratory Diseases (GARD), Turkey), C. Gomes (ANTDR, Associac ¸a ˜o Nacional da Tuberculose e Doenc ¸as Respirato ´rias, Portugal), J. Gomez Vera (Colegio Mexicano de Inmunologı ´a Clı ´nica y Alergia), M. Gonsalves (Porto Age-Up consortium, Portugal), R.A. Gonza ´lez Galva ´n (COMPENDIA, Mexico), M. Gotua (Center of Allergy and Immunology, Georgian Association of Allergology and Clinical Immunology, Tbilisi, Georgia), L. Grouse (University of Washington School of Medicine, Faculty of the Department of Neurology, USA), K. Gryga (Polish Alliance against Chronic Respiratory Diseases), J. Guggiari (SLaai, Sociedad Latinoamericana de Allergia, Asma e Immunologia), A. Gu ¨ndog ˘an (Global Alliance against Chronic Respiratory Diseases (GARD), Turkey), M.A. Guzma ´n (ARIA, Allergic Rhinitis and Its Impact on Asthma; Immunology and Allergology Division, Dept of Medicine, Clinical Hospital University of Chile, Chile), T. Haahtela (MeDALL, Mechanisms of the Development of Allergy; ARIA, Allergic Rhinitis and Its Impact on Asthma; Dept