[Is the introduction of clinical management programs for patients with chronic obstructive pulmonary disease useful? Comparison of the effectiveness of two interventions on the clinical progress and care received]. / ¿Es útil la implantación de programas de gestión clínica de los pacientes con enfermedad pulmonar obstructiva crónica? Comparación de la efectividad de dos intervenciones sobre la evolución clínica y la atención recibida.

OBJECTIVE: To evaluate the effectiveness of two management programs on patients with chronic obstructive pulmonary disease (COPD). DESIGN: A study with a quasi-experimental design was used to evaluate the effectiveness of two interventions (I1, I2) for the care of patients with COPD after a mean follow-up of 31.2months. SETTING: Primary Care Centres in two Barcelona Health Areas and their referral hospitals. PARTICIPANTS: Patients with COPD selected by simple random sampling using any disease code corresponding to COPD. INTERVENTIONS: I1: Integrated management program that was optimised and coordinated the resources. Training was given, as well as quality control of spirometry. I2: Isolated interventions like a call-centre. Care circuits and computerised clinical notes were shared. MAIN MEASUREMENTS: Variables were recorded as regards lung function, severity, use of inhalers, lifestyles, quality of life, and exacerbations. RESULTS: Of the 393 patients evaluated at the beginning, 120 and 104 (I1 and I2, respectively) received the final evaluation. With I1, there was a reduction in patients who smoked (P=.034). Lung function and quality of life did not change significantly in either group, but shortness of breath was slightly worse. There was an increase in the correct use of inhalers, although it only reached 48% and 61% with interventions I1 and I2, respectively. The percentage of patients with exacerbations decreased with I1 compared to that of I2 (P<.001), and there were less hospital admissions due to exacerbations with I2 compared to I1 (P<.003]). CONCLUSIONS: Both interventions achieved significant improvements, and no overall worsening of a chronic and progressive disease as is COPD.

Effect of health professional education on outcomes of chronic obstructive pulmonary disease in primary care: a non-randomized clinical trial.

BACKGROUND AND OBJECTIVE: The best strategy to achieve optimal integrated management to patients with chronic obstructive pulmonary disease (COPD) in primary care (PC) is not clear. We aimed to evaluate the effectiveness of an intervention in PC based on an integrated programme, which combines diverse strategies directed at health professionals to improve quality of life and clinical outcomes of their patients with COPD. We compared the outcome with results from standard practice. METHODS: A prospective, multicentre, quasi-experimental study and a 12-month follow up was performed. Intervention consisted of an integrated education programme in PC. The main outcome variable was the change in total score of the St. George's Respiratory Questionnaire (SGRQ) at the end of follow up between the control and intervention group. RESULTS: A total of 801 patients participated in the study with a mean age of 70.2 years and a mean FEV1 (% predicted) of 55%. At 1-year follow up, the SGRQ score did not significantly differ. Although the intervention group showed an improvement in dietary, exercise and smoking habits, there was an increase in reported exacerbations and hospital admissions (P < 0.001). CONCLUSIONS: Implementation of an integrated education programme in a PC setting, which combines diverse strategies directed at health professionals, did not achieve the expected changes in quality of life measured by SGRQ at 1-year follow up. Nonetheless, this study observed an improvement in patients' lifestyle choices, even though this did not result in a significant change in the clinical evolution or heath status over 12 months.

Evaluation of a combined strategy directed towards health-care professionals and patients with chronic obstructive pulmonary disease (COPD): information and health education feedback for improving clinical monitoring and quality-of-life.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a health problem that is becoming increasingly attended-to in Primary Care (PC). However, there is a scarcity of health-care programs and studies exploring the implementation of Clinical Practice Guidelines (CPG). The principal objective of the present study is to evaluate the effectiveness of a combined strategy directed towards health-care professionals and patients to improve the grade of clinical control and the quality-of-life (QoL) of the patients via a feedback on their state-of-health. A training plan for the health-care professionals is based on CPG and health education. METHOD/DESIGN: Multi-centred, before-after, quasi experimental, prospective study involving an intervention group and a control group of individuals followed-up for 12 months. The patients receive attention from urban and semi-urban Primary Care Centres (PCC) within the administrative area of the Costa de Ponent (near Barcelona). All the pacients corresponding to the PCC of one sub-area were assigned to the intervention group and patients from the rest of sub-areas to the group control. The intervention includes providing data to the health-care professionals (clinician/nurse) derived from a clinical history and an interview. A course of training focused on aspects of CPG, motivational interview and health education (tobacco, inhalers, diet, physical exercise, physiotherapy). The sample random includes a total of 801 patients (> or = 40 years of age), recorded as having COPD, receiving attention in the PCC or at home, who have had at least one clinical visit, and who provided written informed consent to participation in the study. Data collected include socio-demographic characteristics, drug treatment, exacerbations and hospital admissions, evaluation of inhaler use, tobacco consumption and life-style and health-care resources consumed. The main endpoints are dyspnoea, according to the modified scale of the Medical Research Council (MRC) and the QoL, evaluated with the St George's Respiratory Questionnaire (SGRQ). The variables are obtained at the start and the end of the intervention. Information from follow-up visits focuses on the changes in life-style activities of the patient. DISCUSSION: This study is conducted with the objective of generating evidence that shows that implementation of awareness programs directed towards health-care professionals as well as patients in the context of PC can produce an increase in the QoL and a decrease in the disease exacerbation, compared to standard clinical practice. TRIAL REGISTRATION: Clinical Trials.gov Identifier: NCT00922545;

Assessment of a primary and tertiary care integrated management model for chronic obstructive pulmonary disease.

BACKGROUND: The diagnosis and treatment of patients with chronic obstructive pulmonary disease (COPD) in Spain continues to present challenges, and problems are exacerbated when there is a lack of coordinated follow-up between levels of care. This paper sets out the protocol for assessing the impact of an integrated management model for the care of patients with COPD. The new model will be evaluated in terms of 1) improvement in the rational utilization of health-care services and 2) benefits reflected in improved health status and quality of life for patients. METHODS/DESIGN: A quasi-experimental study of the effectiveness of a COPD management model called COPD PROCESS. The patients in the study cohorts will be residents of neighborhoods served by two referral hospitals in Barcelona, Spain. One area comprises the intervention group (n = 32,248 patients) and the other the control group (n = 32,114 patients). The study will include pre- and post-intervention assessment 18 months after the program goes into effect. Analyses will be on two datasets: clinical and administrative data available for all patients, and clinical assessment information for a cohort of 440 patients sampled randomly from the intervention and control areas. The main endpoints will be the hospitalization rates in the two health-care areas and quality-of-life measures in the two cohorts. DISCUSSION: The COPD PROCESS model foresees the integrated multidisciplinary management of interventions at different levels of the health-care system through coordinated routine clinical practice. It will put into practice diagnostic and treatment procedures that are based on current evidence, multidisciplinary consensus, and efficient use of available resources. Care pathways in this model are defined in terms of patient characteristics, level of disease severity and the presence or absence of exacerbation. The protocol covers the full range of care from primary prevention to treatment of complex cases.

Underdetection and underreporting of pertussis in children attended in primary health care centers: Do surveillance systems require improvement?

BACKGROUND: Pertussis is an underestimated disease. Several European countries have developed models to account for underreporting of pertussis. The aim of this study was to estimate pertussis underdetection and underreporting in pediatric patients attending primary health care centers (PHCCs). METHODS: We reviewed clinical records of PHCCs in Barcelona in 2012. Factors associated with underdetection and underreporting were analyzed by logistic regression. Adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) were calculated. RESULTS: We included 3,505 children aged < 7 years (mean age, 34 ± 20.7 months; range, 0-82 months) presenting with cough; 9.3% (326 out of 3,505) of patients also had ≥ 1 symptoms related to pertussis accompanied by cough for a duration ≥ 2 weeks. Of the 326 children receiving clinical criteria, only 31 (9.5%) were laboratory-confirmed and 6 (1.8%) were detected but not reported. There were 295 (90.5%) undetected suspected pertussis cases. Age ≥ 18 months (aOR, 8.51; 95% CI, 1.82-39.86), cyanosis (aOR, 6.71; 95% CI, 1.43-31.39), request for chest radiograph (aOR, 0.26; 95% CI, 0.07-0.99), and request for other laboratory tests (aOR, 5.39; 95% CI, 2.19-13.27) were associated with underdetection. Paroxysmal cough (aOR, 5.77; 95% CI, 1.05-31.76) and request for other laboratory tests (aOR, 2.91; 95% CI, 1.11-7.62) were associated with underreporting. CONCLUSIONS: Both underdetection and underreporting complicate the understanding of pertussis epidemiology. Correct assessment of pertussis symptoms and notification of cases must be improved to control pertussis.

Factors associated with changes in quality of life of COPD patients: a prospective study in primary care.

BACKGROUND: A primary objective in the treatment of patients with chronic obstructive pulmonary disease (COPD) is to improve their health status. OBJECTIVE: To identify the factors associated with changes in health-related quality of life (HRQoL) in patients with COPD after one year of follow-up in primary care. METHOD: Multicenter, prospective study with one year of follow-up. The end-point was the change in total score on the Saint George's Respiratory Questionnaire (SGRQ). Patients with a clinically relevant (>4 points) decrease or increase in SGRQ total score were compared. Factors associated with the changes in HRQoL observed after one year were determined by logistic regression analysis. RESULTS: A total of 791 patients (mean age, 70.2 years) were analyzed. Mean FEV1 (% predicted) was 52.4%. Average total SGQR score was 37.1 (SD = 19.1) at baseline and 35.6 (SD = 18.9) at follow-up. Significantly improved HRQoL was observed in 36.7% of patients, and was associated with starting polymedication, pulmonology visits, and balanced diet; ending respiratory rehabilitation, quitting smoking; and not being a frequent exacerbator. Quality of life worsened significantly in 29.2% of patients, and was associated with worsening respiratory symptoms and increased hospital admissions. CONCLUSIONS: Although overall changes in HRQoL observed after one year were minimal, more than one third of patients improved significantly, and one third had significantly worse HRQoL. Clinical factors were independently associated with these changes, emphasizing the relevance to improved HRQoL of starting a healthy lifestyle and respiratory treatments and the negative impact on HRQoL of COPD symptoms onset and admissions.

[Treating COPD in chronic patients in a primary-care setting]. / Atención a la EPOC en el abordaje al paciente crónico en atención primaria.

The aging of the populations in Western countries entails an increase in chronic diseases, which becomes evident with the triad of age, comorbidities and polymedication. chronic obstructive pulmonary disease represents one of the most important causes of morbidity and mortality, with a prevalence in Spain of 10.2% in the population aged 40 to 80. In recent years, it has come to be defined not only as an obstructive pulmonary disease, but also as a systemic disease. Some aspects stand out in its management: smoking, the main risk factor, even though avoidable, is an important health problem; very important levels of underdiagnosis and little diagnostic accuracy, with inadequate use of spirometry; chronic patient profile; exacerbations that affect survival and cause repeated hospitalizations; mobilization of numerous health-care resources; need to propose integral care (health-care education, rehabilitation, promotion of self-care and patient involvement in decision-making).

[Proportion of individuals with indication criteria for bone densitometry and frequency of factors of risk of low osseous mass in primary care consultations]. / Proporción de individuos con criterios de indicación de densitometría ósea y frecuencia de los factores de riesgo de baja masa ósea en consultas de atención primaria.

OBJECTIVE: To find the number of individuals with indication for Bone Densitometry in Primary Care, according to the criteria of the WHO, the Agency for Evaluating Medical Technology of Catalonia (AETM) and the International Committee on Clinical Guides to Osteoporosis (CIGCO), and the frequency of factors of risk of low osseous mass. DESIGN: Multi-centre, prospective, transversal study. SETTING: Primary care consultations. PARTICIPANTS: Patients over 18 (307 women and 139 men) with mean age of 54.3+/-16.8, who attended for consultation with an appointment. MAIN MEASUREMENTS: Presence or absence of factors relating to each of the indication criteria for bone densitometry. RESULTS: A 36.3% of individuals had indication of densitometry under the AETM criteria, 76.7% with the WHO criteria, and 50.5% with the CIGCO criteria (applicable only to women). Percentages increased with age and were higher for women. Concordance between the various criteria was under 37%. CONCLUSIONS: The percentage of individuals with indication for bone densitometry was highly variable under different criteria. It was greater in women and increased with age. Concordance between different criteria was low.