Prevalence of COPD in Spain: impact of undiagnosed COPD on quality of life and daily life activities.

AIMS: This study aimed to determine the prevalence of chronic obstructive pulmonary disease (COPD) in Spain and identify the level of undiagnosed disease and its impact on health-related quality of life (HRQL) and activities of daily living (ADL). METHODS: A population-based sample of 4274 adults aged 40-80 years was surveyed. They were invited to answer a questionnaire and undergo prebrochodilator and postbronchodilator spirometry. COPD was defined as a postbronchodilator FEV(1)/FVC (forced expiratory volume in 1 s/forced vital capacity) ratio of <0.70. RESULTS: For 3802 participants with good-quality postbronchodilator spirometry, the overall prevalence of COPD was 10.2% (95% CI 9.2% to 11.1%) and was higher in men (15.1%) than in women (5.6%). The prevalence of COPD stage II or higher was 4.4% (95%CI; 3.8%-5.1%). The prevalence of COPD increased with age and with cigarette smoking and was higher in those with a low educational level. A previous diagnosis of COPD was reported by only 27% of those with COPD. Diagnosed patients had more severe disease, higher cumulative tobacco consumption and more severely impaired HRQL compared with undiagnosed subjects. However, even patients with undiagnosed COPD stage I+ already showed impairment in HRQL and in some aspects of ADL compared with participants without COPD. CONCLUSIONS: The prevalence of COPD in individuals between 40 and 80 years of age in Spain is 10.2% and increases with age, tobacco consumption and lower educational levels. The rate of diagnosised COPD is very high and undiagnosed individuals with COPD already have a significant impairment in HRQL and ADL.

[The EPI-SCAN survey to assess the prevalence of chronic obstructive pulmonary disease in Spanish 40-to-80-year-olds: protocol summary]. / Estudio EPI-SCAN: resumen del protocolo de un estudio para estimar la prevalencia de EPOC en personas de 40 a 80 años en España.

BACKGROUND AND OBJECTIVES: Chronic obstructive pulmonary disease (COPD) causes considerable morbidity and mortality in Spain. The 1997 IBERPOC study, applying the old criteria of the European Respiratory Society, reported a COPD prevalence of 9.1% in the adult population of Spain. The Epidemiologic Study of COPD in Spain (EPI-SCAN) aims to determine the current prevalence of COPD in residents of Spain aged 40-80 years and to estimate changes over the past 10 years. Secondary objectives are, among others, to describe the current prevalence of smoking and changes in COPD prevalence relative to previous studies; to describe treatments received by patients, quality of life, and the BODE index (body mass index, obstruction of airflow, dyspnea, and exercise tolerance); and to measure inflammatory markers in blood and exhaled-breath condensate. PATIENTS AND METHODS: EPI-SCAN is a population-based, cross-sectional epidemiologic study targeting the general population of Spain aged between 40 and 80 years. Participating centers were located in Barcelona, Burgos, Cordoba, Huesca, Madrid, Oviedo, Seville, Valencia, Vic, and Vigo. All subjects filled in an extensive questionnaire to collect social, demographic, and clinical information. Slow and forced spirometry tests before and after a bronchodilator test were also undertaken. Additionally, selected subjects performed a 6-minute walk test and answered generic and specific quality-of-life questionnaires, as well as an activities-of-daily-living questionnaire. Exhaled-breath condensate and blood samples were also collected from these subjects for measurement of inflammatory and other biomarkers.

Influence of three factors on the diagnostic effectiveness of transthoracic needle aspiration in pneumonia.

Prior antibiotic therapy, size of the infiltrate, and the person who performed the technique were the three factors that we studied to assess their influence on the effectiveness of transthoracic needle aspiration (TNA). Ninety-one patients with a diagnosis of severe bacterial pneumonia, who underwent TNA, have been included in the study. The technique was carried out with an ultrathin needle gauge 25 and without fluoroscopic control. A univariate (UA) and a multivariate statistical analysis were made. The sensitivity of TNA was 34.1%. Fifty-seven of 91 (62.6%) had received antibiotic therapy prior to TNA; sensitivity was higher in nontreated patients than in treated patients (p = 0.0033; UA). There were 34 patients with an infiltrate that was smaller than a lobe (MINLOB); 39 cases affected a complete lobe (LOB) and 18 more than one lobe (MAJLOB). The TNA sensitivity was higher in LOB cases than in MINLOB cases (p = 0.0004; UA) while when comparing LOB cases and MAJLOB cases, sensitivity was higher in the former (p = NS; UA). In 28 of 91 cases (30.8%), the TNA was performed by A (a trained physician who regularly carries out the technique) and in 63 of 91 cases (69.2%) by B (other physicians, 10 in our study, who sporadically perform the technique). The TNA sensitivity was higher when the technique was performed by A, although this difference was not significant; if we add negative TNA with leukocytes present in Gram stains (which would indicate that aspiration was done in the correct area) to positive TNA, the difference between A and B was higher (p = 0.0248). The multivariate statistical analysis confirmed that there are two variables that are independently connected to a positive TNA (prior antibiotic therapy and size of the infiltrate). As regards the variable "person who carries out the technique," a significant association with a positive TNA was not established, although the estimations we obtained show a possible clinical relevance.

Smoking characteristics: differences in attitudes and dependence between healthy smokers and smokers with COPD.

OBJECTIVE: To ascertain the differences in smoking characteristics between a group of smokers with COPD and another group of healthy smokers, both of which were identified in a population-based epidemiologic study. DESIGN AND PARTICIPANTS: This is an epidemiologic, multicenter, population-based study conducted in seven areas of SPAIN: A total of 4,035 individuals, men and women aged 40 to 69 years, who were selected randomly from a target population of 236,412 subjects, participated in the study. INTERVENTIONS: Eligible subjects answered the European Commission for Steel and Coal questionnaire. Spirometry was performed followed by a bronchodilator test when bronchial obstruction was present. The Fagerström questionnaire was used for study of the degree of physical nicotine dependence, and the Prochazka model was followed for analysis of the smoking cessation phase. RESULTS: Of 1,023 active smokers, 153 (15%) met the criteria for COPD. Smokers with COPD were more frequently men (odds ratio [OR], 2.18; 95% confidence interval [CI], 1.21 to 3.95), were > or = 46 years of age (OR, 1.97; 95% CI, 1.18 to 3.31), had a lower educational level (OR, 1.96; 95% CI, 1.23 to 3.14), and had smoked > 30 pack-years (OR, 3.70; 95% CI, 2.42 to 5.65). Smokers with COPD showed a higher dependence on nicotine than healthy smokers (mean [+/- SD] Fagerström test score, 4.77 +/- 2.45 vs 3.15 +/- 2.38, respectively; p < 0.001) and higher concentrations of CO in exhaled air (mean concentration, 19.7 +/- 16.3 vs 15.4 +/- 12.1 ppm, respectively; p < 0.0001). Thirty-four percent of smokers with COPD and 38.5% of smokers without COPD had never tried to stop smoking. CONCLUSIONS: Smokers with COPD have higher tobacco consumption, higher dependence on nicotine, and higher concentrations of CO in exhaled air, suggesting a different pattern of cigarette smoking. Cases of COPD among smokers predominate in men and in individuals with lower educational levels. A significant proportion of smokers have never tried to stop smoking; thus, advice on cessation should be reinforced in both groups of smokers.

Low-dose formoterol Turbuhaler (Oxis) b.i.d., a 3-month placebo-controlled comparison with terbutaline (q.i.d.).

This study compared the efficacy of a low dose of formoterol Turbuhaler 6 micrograms b.i.d. (F) with that of terbutaline 0.5 mg q.i.d. (T), and placebo (P) from Turbuhaler. After a 2-week run-in, 397 adults with mild to moderate asthma were randomly allocated to one of the treatments for 12 weeks. During run-in, the mean morning peak expiratory flow (PEF) was 360 (F), 368 (T) and 367 1 min-1 (P). F was better than T (P = 0.014) and P (P = 0.0001) in improving morning PEF [mean changes from run-in: 20 (F), 9 (T), and 21 min-1 (P)]. F was statistically significantly more effective than either T or P in reducing asthma symptoms. F gave also statistically significantly higher evening PEF and less use of rescue medication than P. Bronchodilator response to study drugs and additional 1.25 mg terbutaline was similar before and after the 12-week treatment period. There were no adverse effects of clinical relevance. In conclusion, formoterol Turbuhaler, 6 micrograms b.i.d. was more effective in improving PEF and offered better asthma control than either terbutaline Turbuhaler, 0.5 mg q.i.d. or placebo. Regular use of formoterol did not reduce the bronchodilator response to additional terbutaline. There were no clinically relevant adverse effects.

[Current use, methodology and evaluation of nonspecific bronchial provocation tests in our country]. / Implantación, metodología y valoración de las pruebas de provocación bronquial inespecíficas en nuestro país.

With the aim of determining the current use of non-specific bronchial inhalation challenge (BIC) testing in Spain, 147 questionnaires were sent to hospitals with pneumology departments or units. The questionnaire covered general, technical and methodological aspects of this diagnostic procedure, as well as its assessment and interpretation. Of the 42 informants who returned questionnaires, mainly from large urban hospitals, 34 reported using BIC. The most widespread criterion applied in deciding to use BIC was the presence of atypical asthma symptoms (33/34). The stimulus most often used was methacholine inhalation (33/34). We found that technical preparation of the drug was highly standardized, but that administration and follow-up protocols differed greatly. There was also great variety in the PC20/PD20 value assigned to indicate bronchial hyperresponsiveness. This study contributes to our better understanding of the current use of BIC in Spain and highlights the need to work toward greater standardization for this diagnostic procedure, to enable us to assess and interpret the results more consistently.

[Asthma emergencies: can we lower the rate of readmission after discharge?]. / Asma en urgencias: podemos disminuir la tasa de reingresos tras el alta?

INTRODUCTION: The rate of readmission among asthmatic emergency patients varies. In 1991 we observed a 9% rate of readmission following emergency room release. Studies of the number of readmissions or request for medical care are used as the basis for recommendations for releasing patients from hospital emergency care. No studies have assessed disease stability following release or factors related to stability. OBJECTIVES: To assess the course of disease and clinical stability of patients in the period immediately following release from emergency room care. To determine factors that might predict such stability. to determine the rate of readmission in the month following release after applying a treatment protocol and release criteria, with follow-up examination 72 h later. MATERIAL AND METHODS: Prospective, descriptive study with follow-up 72 h and one month after release. SETTING: Emergency and pneumology departments of a general hospital. PERIOD: six months. PATIENTS: 82 asthmatic patients released from the emergency room. RESULTS: Two patients (2.43% were readmitted. At the first follow-up visit (72 h) 81 patients (98.78%) were seen. At the second visit, 66 patients (80.5%) were examined. We observed stability in 70.3% of patients at 72 h and in 86.4% after on month. Stability was statistically related to whether peak expiratory flow greater or less than 70% (76.92% stable versus 46.66% unstable) (p < 0.05). No other clinical, epidemiological or treatment variables recorded upon release were found to influence stability. CONCLUSIONS: 1) A large proportion of patients are in stable condition 72 h after release. 2) When peak expiratory flow upon release is > 70%, stability is significantly increased 72 h later. 3) Our 2.43% rate of readmission one month after release is very low. 4) No differences in stability were seen to be related to oral corticoid prescription upon release.

[Compliance with inhalation treatment of patients with chronic obstructive pulmonary disease]. / Estudio de cumplimiento del tratamiento por vía inhalatoria en pacientes con enfermedad pulmonar obstructiva crónica.

OBJECTIVES: To evaluate patient compliance with inhaled medication therapy in chronic obstructive pulmonary disease (COPD), to identify determining factors and to propose corrective measures to improve compliance. METHODS: This was an open, observational, cross-sectional, non-comparative, single-measurement, non-random study. The inhalers were the Serevent Accuhaler, the Serevent Inhalador and the Flixotide Inhaler. Compliance was measured in four ways: a) difference in weight at the beginning and end of the study for all devices; b) dose counter reading for the Accuhaler; c) information from patient diaries (by days and by applications); and d) information from patient interviews using the Morinsky-Green Test. Compliance was rated as follows: poor: < 50%, fair 51%-79%, good 80%-119%, or "hypercompliant" > 120%. RESULTS: Seventy-two patients (mean age 65 years) were enrolled. Compliance measured by weight was good in 77.1%, fair in 11.5%, poor in 1.4% and hypercompliant in 10%. Compliance was good for the Accuhaler according to both weight (75%) and counted doses (83.3%). According to patient diaries, compliance was good when assessed by applications (98.8%) and by days (98.3%). According to the Morinksky-Green test, compliance was good for 87.9%. CONCLUSIONS: Compliance was good as assessed by the methods used in this study. Patients who live in families, who enjoy a high socioeconomic level, have simple therapeutic regimens and have a good understanding of their disease and inhaler tend to have good compliance. Careful patient follow-up and good patient-physician communication has improved compliance. However, follow-up studies are needed to check these results.

[Smoking habits among sixth-year medical students in Spain]. / Consumo de tabaco en estudiantes de sexto curso de medicina de España.

OBJECTIVE: To describe and analyze the smoking habits of sixth-year Spanish medical students. MATERIAL AND METHODS: The target population of this descriptive cross-sectional study was students completing their sixth year in Spanish medical schools. An anonymous, self-administered questionnaire was sent to the students' homes by ordinary mail. The relationships between the variables were analyzed using contingency tables, the chi2 test, the Student t test, and analysis of variance with a significance level of P< .05. The software package was SPSS. RESULTS: A total of 3840 questionnaires were distributed to students, and 1340 were returned completed (34.9%). Of the respondents, 27% were smokers (8.7% smoked only on weekends, and 18.3% were daily smokers). The mean (SD) number of cigarettes smoked per day was 10.54 (7.89). Consumption was significantly higher among men than among women. The mean age of initiation was 17.20 years. Of the students who were smokers, 32.54% stated that they had started smoking during their medical studies. The percentage of smokers who stated that they wanted to quit was 76.3%, and 56.6% said that they had already made at least one quit attempt. CONCLUSIONS: It is cause for concern that a large number of students start smoking after they enter medical school. One of the reasons for this is the lack of concern about smoking as a health problem within medical schools. The smoking habits of medical students are affected by the same phenomena that affect those of the general public, such as the increase in the number of women smokers, the influence of sociocultural factors, and the increasingly broader age range of initiation. The lower prevalence of smoking among medical students with respect to other populations is probably due to the fact that, in general, these students have better health habits than the general public, and/or the reasons that led them to study medicine also make them disinclined to smoke.

[Community acquired pneumonia. Reliability of the criteria for deciding ambulatory treatment]. / Neumonía adquirida en la comunidad. Fiabilidad de los criterios para decidir tratamiento ambulatorio.

To determine whether criteria for not admitting community-acquired pneumonia (CAP) patients diagnosed in the emergency room are appropriate, and to characterize the symptoms, etiology and course of CAP. This one-year prospective, protocol study of immunocompetent CAP patients diagnosed in the emergency room of our hospital enrolled patients not considered to require hospital admission according to the recommendations of the Spanish Society of Respiratory Disease (SEPAR). Medical histories, chest X-rays and blood analysis were obtained for all patients. Blood cultures were analyzed for antibodies against Legionella pneumophila, Mycoplasma pneumoniae, Coxiella burnetii, Chlamydia pneumoniae, Chlamydia psittaci and influenza virus types A and B. The patients received erythromycin for 14 days and were regularly checked by the pulmonologist in the outpatient clinic until signs and symptoms had disappeared. One hundred six patients were enrolled. Mean age was 36 +/- 13 years. Only 3 patients had to be admitted to hospital, after which outcome was good. The main symptoms were fever (106, 100%) and cough (83, 78%). In 46 (43.4%) chest sounds were normal. Microbiologic diagnoses were achieved for 28 (26.4%) and Coxiella burnetii was the agent most often found (19, 17.9%). Outcome was good in all cases, with faster disappearance of symptoms than of radiological signs. The SEPAR criteria for admitting patients with CAP are appropriate. The clinical symptoms of such patients are non specific, a noteworthy finding being that many patients had normal chest sounds. Coxiella burnetii was the most common causative agent. Both clinical and radiological outcomes were excellent.

[Usefulness of computerized tomography in the study of pleural effusion with no presumed diagnosis]. / Utilidad de la tomografía computarizada para el estudio del derrame pleural sin presunción diagnóstica.

To establish the diagnostic yield of computerized tomography (CT) in pleural effusions with no presumed diagnosis arising from standard clinical examination. A prospective protocol study enrolling all cases of effusion admitted to our hospital between January 1994 through July 1995 without a presumed diagnosis after initial testing that included thoracocentesis. Twenty-two patients were enrolled. All were given a CT scan as well as other complementary examinations considered appropriate and were referred to our outpatient clinic for follow-up. The CT images were read by an expert radiologist and their contribution was classified as "diagnostic", "suggestive" or "nil". A definitive etiologic diagnosis was achieved in 14 cases (8 neoplasms, 4 benign due to asbestos, 1 tuberculosis and 1 pulmonary embolism). The CT contribution was nil in 13 cases (59%), "diagnostic" in 6 (2 mesotheliomas, 1 hypernephroma, 1 lymphoma, 1 adenocarcinoma of the colon and another of the ovary) and "suggestive" in 3 (2 benign due to asbestos and 1 lymphoma). Positive information was obtained in 9 cases (41%). CT gives good yield in the investigation of pleural effusions with no presumed diagnosis and should be made available to this group of patients before other more invasive procedures are resorted to. It is especially useful for detecting neoplastic disease of the upper abdomen, mesothelioma and sings of unsuspected exposure to asbestos.

[Pneumonia in alcoholic patients: the clinical and etiological characteristics]. / Neumonía en pacientes alcohólicos: características clínicas y etiológicas.

Twenty-four alcoholic patients with community-acquired pneumonia were studied for 2 years in order to define clinical signs and etiology. Blood cultures and serological profiles were done for all patients in addition to standard blood analyses. All had an invasive procedure -transthoracic puncture with an ultrafine 25G needle (20 patients) or telescopic catheter with bacteriologic brush (4 patients). When we were unable to obtain a good sputum sample (5 patients), a culture was grown. The patients' mean age was 48 and 83% had an acute clinical profile (< or = 7 days with symptoms) with "typical" signs. The X-rays showed an alveolar pattern in all patients, with cavitation in 29%. Etiological diagnosis was reached in 17 (71%) cases, with St. Pneumoniae (25%), anaerobic microorganisms (20%) and C. burnetii (12.5%) being the germs found most frequently. The invasive techniques were more useful (54%) than the blood cultures (17%) or sputum cultures (4%), and they were well tolerated and uncomplicated. Empirical antibiotic treatment was modified for 12 patients (50%). Seventeen percent required intensive care treatment and mortality was 12.5%.

[Protected bacteriologic brushing in patients with severe copd]. / El cepillado protegido bacteriológico en pacientes con EPOC severa.

To determine the presence of germs and their concentration in a group of patients with severe chronic obstructive pulmonary disease (COPD) (FEV1 < 50%), some of whom were in stable condition and others of whom were in acute phase. Twenty-six patients with severe COPD (14 stable and 12 acute phase) were enrolled. None had received prior antibiotic or corticoid treatment. The stable patients had no signs or symptoms of exacerbation, whereas the acute-phase patients had increased dyspnea, sputum volume and purulence. The patients received aerosol rather than liquid anesthesia when PSB sampling was performed. A PSB finding was considered positive at a level > or = 10(3) CFU/ml. There were no significant differences between the groups with respect to age, sex, proportion of smokers and ex-smokers or packs per year. The only spirometric measure that was significantly different was (FEV1/FVC, which was lower in the acute-phase group (p < 0.05). Positive PSB findings were recorded for 57.1% of the stable patients and for 66.7% of the acute-phase patients (p = NS). H. influenzae was the microorganism found most often in both groups. The mean CFU/ml level was 8,625 in stable patients and 17,375 in acute-phase patients (p = NS). A large proportion of stable patients (57.1%) with severe COPD harbor significant concentrations of germs as revealed by PSB sampling. Germ concentrations were found in a non significantly greater number of acute-phase patients, confirming the lack of congruence between clinical status and bacteriological condition.

[Early discharge and home health care program for patients with exacerbated COPD and asthma]. / Programa de altas precoces y asistencia domiciliaria en pacientes con exacerbación de enfermedad pulmonar obstructiva crónica y asma.

OBJECTIVE: To shorten hospital stays of patients with exacerbated chronic obstructive pulmonary disease (COPD) or asthma by way of a home care program and to assess whether the program increased the number of readmissions. METHODS: Patients admitted due to COPD exacerbation or asthma who did not need critical care and were discharged before the fourth day. A registered nurse experienced with respiratory disease patients and in regular contact with the pneumologist who supervised the program made follow-up home care visits to give instructions and check compliance with treatment. RESULTS: Sixty-nine patients enrolled in the program, 53 with COPD and 16 with asthma. A mean 7.2 home care visits per patient were made. The mean hospital stay was 3.69 ( 0.5 days for patients receiving home care and 7.89 ( 5 days for those who received no home care (p < 0.005). Severity of COPD in terms of age, FEV1 and PaO2 was similar in both groups, as follows: FEV1 was 39.4 12% and PaO2 66.3 7,7% for patients receiving home care; FEV1 was 40.6 ( 12% and PaO2 was 64.3 ( 7% for those receiving no home care (ns). The mean hospital stay overall for both groups was 7.4 (4.9 days; the mean hospital stay for the same diseases in the same previous the year before the study was 8.3 ( 5.5 (p < 0.05). The rate of readmissions for new exacerbations within 30 days of discharge was 4.3% (3/69) in the group receiving home care and 7.2% (29/401) among patients receiving only hospital care (ns.). A questionnaire survey at the end of the program showed satisfaction to be very high. CONCLUSIONS: A program of home care provided by a registered nurse experienced with respiratory diseases allows mean hospital stay to be reduced without increasing the number of readmissions within 30 days, with high patient satisfaction.

[Prevalence of and attitudes towards smoking in a population over 40 years of age]. / Prevalencia y actitudes sobre tabaquismo en población mayor de 40 años.

OBJECTIVES: Smoking is the main cause of preventable death in developed countries. One of the most relevant health care interventions is convincing smokers to quit. To achieve that end, it is important to know, in addition to the prevalence of smoking, the degree of physical addiction to nicotine and smokers' attitudes toward tobacco. MATERIAL AND METHODS: This study collects results from a Spanish national epidemiological study (the IBERPOC study) related to smoking addiction, smokers' degree of addiction to nicotine and smokers attitudes toward their habits. The data has been obtained by surveying 4,035 individuals selected randomly from census data in seven different parts of the country. Information was obtained from questionnaires and CO in expired air was measured. RESULTS: One thousand fifty-nine respondents were smokers (26%) and 968 were ex-smokers (24%). Female smokers were younger (47 versus 51 years old) and had started smoking later (at age 22 versus 17 years), smoked fewer cigarettes per day (15 versus 21) and had lower concentrations of CO in expired air (13.4 versus 17 ppm) (p < 0.001 for all comparisons). Six hundred fifty-nine smokers (62.2%) had tried to quit at least once. The most important reasons given for trying to quit were related to improving health. CONCLUSIONS: The 26% of the surveyed population smoked. Women generally started later, smoked fewer cigarettes and were less physically addicted to nicotine. Most smokers had tried at least once to quit, particularly if motivated to improve health. These results should be considered when proposing strategies for smoking cessation.

[Spirometry: quality in the respiratory medicine clinics of a public health care area]. / Calidad de la espirometría en las consultas neumológicas de un área jerarquizada.

BACKGROUND: Spirometry can be considered a routine way to evaluate patients with respiratory complaints, both inside and outside the hospital setting. OBJECTIVE: To assess the quality of spirometry in a public health care area with respect to two factors: the technicians' performance and the calibration of spirometers. MATERIAL AND METHOD: Four health care clinics were studied. Four technicians participated and the four spirometers were tested at different volumes (calibration syringes 1L and 3L) and different flows (explosive decompression). Eight patients with COPD participated in the study of inter-technician variability. RESULTS: Agreement among the technicians was very high: 0.98-0.99 for FEV1 and 0.91-0.98 for FVC. The mean results obtained by the technicians were: FEV1 = 2.15 0.03, range 2.20-2.14; FVC = 3.25 0.05, range 3.30-3.21 (ns). Volumetric readings from the spirometers were correct for the 1I calibration syringe, but 2 out of 4 spirometers lost linearity with the 3I calibration syringe. One spirometer gave readings out of range for all flow levels, and 2 out of 4 spirometers were out of range at low flows. CONCLUSIONS: 1. Results obtained by different technicians were not significantly different and there was high agreement among them, confirming that performance of spirometry was good. 2. The spirometers showed poor linearity at low flows.

[Costs of chronic obstructive pulmonary disease in Spain. Estimation from a population-based study]. / Costes de la EPOC en España. Estimación a partir de un estudio epidemiológico poblacional.

OBJECTIVE: In the studies carried out to date, the cost of chronic obstructive pulmonary disease (COPD) may have been overestimated due to the inclusion of previously diagnosed patients seeking medical attention for their symptoms. As a result, the severity of the cases included in these studies may have been greater than in an unselected sample of the general population. The aim of the present study was to estimate the direct cost of COPD on the basis of a representative sample of the overall Spanish population between 40 and 69 years of age (from the IBERPOC study). METHOD: The cost was evaluated retrospectively by means of a questionnaire completed by the 363 patients with COPD from the IBERPOC study with questions referring to the previous year. Standardized spirometry was performed on all the patients by a pneumologist in each of the 7 geographical areas in which the study was carried out. RESULTS: Hospitalization accounted for the greatest expenditure (41% of total), followed by drug therapy (37%). The cost was euro;98.39 per patient, and euro;909.50 per previously diagnosed patient. The cost per person of severe COPD was more than 3 times that of moderate COPD and more than 7 times that of mild COPD. The estimated annual cost of COPD in Spain was euro;238.82 million (for 1997). CONCLUSION: The present study, which was the first to estimate the cost of COPD in a representative sample of the general population, found the cost to be lower than in studies analyzing samples of patients with previous diagnoses of COPD. The cost distribution is not in line with recommended health care practices, underlining the need to optimize resources used to monitor and treat the disease, with an emphasis on early diagnosis.

[The internal consistency and content validity of the Spanish version of the Asthma Autonomy Questionnaire]. / Consistencia interna y validez de contenido de la versión española del Asthma Autonomy Questionnaire.

The Asthma Autonomy Questionnaire (AAQ) was designed to evaluate asthmatics' desire to learn about their disease and to make decisions. The AAQ consists of 26 items distributed in two scales: Preferences in the Search for Information (PSI, 8 items) and Preferences in Decision Making (PDM, 6 general items and 12 related to 3 scenarios depicting asthma in stable phase, during mild exacerbation and during severe exacerbation). The aim of this study was to analyze the internal consistency (Cronbach's-coefficient) and content validity (factorial analysis of principal components) of the AAQ. After translation and back translation, the Spanish version of the AAQ was administered to 115 adult asthmatics of both sexes and differing levels of severity. The alpha coefficients for the two scales and 3 scenarios ranged from 0.42 (PSI) to 0.73 (stable phase scenario); only for the stable-phase scenario were values high or statistically acceptable. Factorial analysis reproduced the content of the scales only approximately, with some items proving to relate to factors that were different from the scale they originally belonged to. These results indicate that, in its current formulation, the AAQ presents important measurement problems and revision is advisable.

[Epidemiological study of chronic obstructive pulmonary disease in Spain (IBERPOC): recruitment and field work]. / Estudio epidemiológico de la EPOC en España (IBERPOC): reclutamiento y trabajo de campo.

Chronic obstructive pulmonary disease (COPD) is a large-scale social and health problem. Because prevalence studies have been performed only in certain areas of Spain, the Spanish Society of Pneumology and Chest Surgery initiated the IBERPOC study with the aim of determining the prevalence of COPD in several parts of the country. IBERPOC is a multicenter, population-based epidemiological study in which subjects have been selected randomly. Seven full-time pneumologists work full-time in seven different areas of Spain. A study of this nature involves a series of difficulties that should be taken into account at the time of planning studies of a similar nature. After 5,827 attempts to reach subjects, a total of 4,967 useful contacts were made, to provide 97.3% of the 5,104 contacts expected. Of those 4,967 useful contacts, 4,035 subjects completed interviews. Among the 932 refusals, 882 (94.6%) agreed to answer a short telephone questionnaire. The field work took 13 months to complete, 30% more time than had been anticipated. The rates at which subjects could not be traced differed from one zone to another, ranging between 5% and 30%; higher rates were attributable to the absence of telephone data in the corresponding census report. In one zone, the dispersion of the census population over a very large area supposed greater difficulty and delay in carrying out the study. In conclusion, the rate of participation and the time required for recruitment can be considered satisfactory. The performance of field work by trained, full-time pneumologists has been essential to the development and quality of the study. Similar epidemiological studies should consider problems derived from the lack of adequate census data, as well as to avoid defining areas of extreme population dispersion in order to facilitate field work.

[Epidemiological study of chronic obstructive pulmonary disease in Spain (IBERPOC): prevalence of chronic respiratory symptoms and airflow limitation]. / Estudio IBERPOC en España: prevalencia de síntomas respiratorios habituales y de limitación crónica al flujo aéreo.

The prevalence of chronic respiratory symptoms and chronic airflow limitation (CAFL) was determined in a multicentric epidemiological study carried out in seven different areas of Spain. Based on a target population of 236,412 persons, a random census sample of 4,035 individuals between 40 and 69 years of age was chosen. Subjects answered several questionnaires and performed spirometric tests followed by a bronchodilation test if bronchial obstruction was detected. Respiratory symptoms were reported by 48% of the population (95% CI: 46.4-49.5%) with greater frequency of symptoms among men than women (55.2% versus 41%, p < 0.001). The following levels of prevalence of chronic symptoms were found: cough, 13.5% (95% CI: 12.5-14.6%); expectoration, 10.7% (95% CI: 9.7-11.6%); dyspnea after one flight of stairs, 10.4% (95% CI: 9.5-11.4%); and wheezing, 40.2% (95% CI: 38.7-41.7%). The prevalence of chronic bronchitis (CB) was 4.8% (95% CI: 4.1-5.4%) and was more frequent among men than among women (8.3% and 1.4%, respectively; p < 0.001). Asthma had been diagnosed previously in 4.9% (95% CI: 4.2-5.5%), more often in women than in men (5.8% and 3.8%, respectively; p < 0.003). CAFL was found in 10.6% (95% CI: 9.6-11.5%), 15.8% in men and 5.5% in women (p < 0.001). All respiratory symptoms except asthma were more frequent among smokers than among ex-smokers, and in turn were more common among ex-smokers than non-smokers. The frequency of symptoms increased in accordance with accumulated smoking. The prevalence of CB and CAFL was vastly different from one region to another. Multivariate analysis showed that factors associated independently with the appearance of CB were smoking, age over 60 years, male sex and having worked in industry. In conclusion, respiratory symptoms, including CB and CAFL, are common in the Spanish population. Smoking and amount of smoking are directly related to the frequency of such symptoms. Substantial differences were found in the prevalence of CB and CAFL among the regions where the study was performed.