The importance of reminders and patient preferences to improve inhaler technique in older adults with COPD.

Objectives: Medication non-adherence in patients with chronic obstructive pulmonary disease is common. The aim is to evaluate the efficacy of two interventions to improve the inhalation technique (IT) in patients with pulmonary disease is common. Also determine optimal IT reminder time and to test the role of preferences in the intervention selection. Method: 726 pulmonary disease in common patients (consecutive sampling) from two trials: 1) TECEPOC-study (patients' preference trial/comprehensive cohort design) 2) TIEPOC-study (randomised controlled trial). Interventions: intervention-A (ad-hoc leaflet with instructions about correct IT according Spanish Respiratory Society), intervention B (intervention A+ individual training by instructors). Four visits were performed (baseline, 3, 6 and 12 months). Data on IT, sociodemographic and clinical characteristics, quality of life and respiratory drugs were recorded. Analysis under intention to treat principle. Multivariate analysis was conducted to measure the potential modifying factors of improvement in the IT along follow-up. Results: 660 patients (90.9%) did not perform a correct IT at baseline 89.75% with Handihaler, 86.95% with Turbuhaler, 84.75% with Accuhaler and 87.35% with pMDI. At 12 months, 221 patients 29.9% performed correctly the IT; a decrease in the slope of the curve (correct IT) was detected at 3 months follow-up. Intervention B was the most effective in both trials compared to control group or intervention A, regardless of preferences: 1) TECEPOC Study (preference trial): Intervention B versus control group, NNT = 3.22 (IC95%, 2.27-5.52); and versus Intervention A, NNT = 3.57 (CI95%, 2.41-6.8). Preferences improved 6.7% in the correct IT without statistical significance. 2) TIEPOC Study (randomized controlled trial): Intervention B versus control group, NNT = 1.74 (IC95%, 1.47-2.17), and versus intervention A, NNT = 3.33 (CI 95%, 2.43-5.55). No differences were measured between Intervention A and control group. Conclusion: Individual training significantly improves IT. Reminders every 3 months are recommended. Preferences do not influence the intervention effectiveness.

Evaluación de tecnologías sanitarias nuevas y emergentes. Propuesta de clasificación / Evaluation of new and emerging health technologies. Proposal for classification

Objetivo. Revisar y desarrollar una propuesta de clasificación de tecnologías sanitarias (TS) evaluadas por las Agencias de Evaluación de Tecnologías Sanitarias (AETS). Métodos. Revisión por expertos de AETS de una propuesta de clasificación de TS. Análisis de sus aportaciones y sugerencias de modificación. Reelaboración de la propuesta de clasificación. Pilotaje con médicos. El emplazamiento fue el Sistema Sanitario Público Andaluz (SSPA) y las AETS españolas. Los participantes eran expertos de AETS y médicos tutores de MIR (médicos internos residentes). La metodología consistió en la actualización de la clasificación de TS previamente realizada por el equipo de investigación, la revisión por expertos de las AETS españolas, el análisis cualitativo y cuantitativo de respuestas y la reelaboración de la clasificación y pilotaje con médicos asistenciales sobre 12 informes de evaluación de las AETS. Resultados. Se obtuvieron 11 categorías temáticas que se clasifican en 6 grandes grupos matrices en función de su finalidad: 1, tecnologías preventivas; 2, tecnologías diagnósticas; 3, tecnologías terapéuticas; 4, tecnologías diagnósticas y terapéuticas; 5, tecnologías organizativas, y 6, gestión del conocimiento y calidad. En el pilotaje se observó la coincidencia en la clasificación de 8 de los 12 informes revisados por los médicos. Conclusiones. En el presente estudio se han consensuado 11 categorías temáticas de TS y se ha propuesto una nueva clasificación de TS con doble entrada, según tipo de TS considerada y según finalidad de la misma. En opinión de los expertos participantes, la clasificación de la labor de las AETS puede representar una herramienta útil para la gestión del conocimiento y la transferibilidad de la labor realizada. Además, una adecuada vehiculización de dicha labor facilitaría su acceso a los usuarios, potenciando así su difusión(AU)

Aims. Review and develop a proposal for the classification of health technologies (HT) evaluated by the Health Technology Assessment Agencies (HTAA). Design. Peer review of AETS of the previous proposed classification of HT. Analysis of their input and suggestions for amendments. Construction of a new classification. Pilot study with physicians. Setting. Andalusian Public Health System. Spanish HTAA. Participants. Experts from HTAA. Tutors of family medicine residents. Method. HT Update classification previously made by the research team. Peer review by Spanish HTAA. Qualitative and quantitative analysis of responses. Construction of a new and pilot study based on 12 evaluation reports of the HTAA. Results. We obtained 11 thematic categories that are classified into 6 major head groups: 1, prevention technology; 2, diagnostic technology; 3, therapeutic technologies; 4, diagnostic and therapeutic technologies; 5, organizational technology, and 6, knowledge management and quality of care. In the pilot there was a good concordance in the classification of 8 of the 12 reports reviewed by physicians. Conclusions. Experts agree on 11 thematic categories of HT. A new classification of HT with double entry (Nature and purpose of HT) is proposed. Applicability. According to experts, the classification of the work of the HTAA may represent a useful tool to transfer and manage knowledge. Moreover, an adequate classification of the HTAA reports would help clinicians and other potential users to locate them and this can facilitate their dissemination(AU)

[Evaluation of new and emerging health technologies. Proposal for classification]. / Evaluación de tecnologías sanitarias nuevas y emergentes. Propuesta de clasificación.

AIMS: Review and develop a proposal for the classification of health technologies (HT) evaluated by the Health Technology Assessment Agencies (HTAA). DESIGN: Peer review of AETS of the previous proposed classification of HT. Analysis of their input and suggestions for amendments. Construction of a new classification. Pilot study with physicians. SETTING: Andalusian Public Health System. Spanish HTAA. PARTICIPANTS: Experts from HTAA. Tutors of family medicine residents. METHOD: HT Update classification previously made by the research team. Peer review by Spanish HTAA. Qualitative and quantitative analysis of responses. Construction of a new and pilot study based on 12 evaluation reports of the HTAA. RESULTS: We obtained 11 thematic categories that are classified into 6 major head groups: 1, prevention technology; 2, diagnostic technology; 3, therapeutic technologies; 4, diagnostic and therapeutic technologies; 5, organizational technology, and 6, knowledge management and quality of care. In the pilot there was a good concordance in the classification of 8 of the 12 reports reviewed by physicians. CONCLUSIONS: Experts agree on 11 thematic categories of HT. A new classification of HT with double entry (Nature and purpose of HT) is proposed. APPLICABILITY: According to experts, the classification of the work of the HTAA may represent a useful tool to transfer and manage knowledge. Moreover, an adequate classification of the HTAA reports would help clinicians and other potential users to locate them and this can facilitate their dissemination.

[Cost-effectiveness analysis of tiotropium compared to ipratropium and salmeterol]. / Análisis del coste-eficacia del tiotropio frente al ipratropio y salmeterol.

OBJECTIVE: The constant increase in health care costs, in a context of limited resources and the appearance of more costly though more effective drugs, justifies an assessment of the pharmacoeconomics of these drugs. The objective of this study was to evaluate the cost-effectiveness of one of the newest drugs for the treatment of chronic obstructive pulmonary disease (COPD)-tiotropium. MATERIAL AND METHOD: A cost-effectiveness analysis (costs and outcomes) within the framework of the Spanish National Health System was done. The alternatives to tiotropium analyzed were ipratropium and salmeterol. Direct health care costs associated with hospital treatment were calculated. Forced expiratory volume in 1 second, quality of life (with the Saint George's Respiratory Questionnaire), dyspnea transitional index, mean stay in hospital, and exacerbations were the variables used to measure effectiveness. Values for these variables were taken from the main reviews and randomized clinical trials published for tiotropium. RESULTS: For COPD patients, treatment with tiotropium leads to a greater reduction in exacerbations (37% compared to ipratropium and 25% compared to salmeterol 25%), and a reduction in the number of days in hospital (33% compared to ipratropium and 14% compared to salmeterol). Therefore, use of tiotropium could save ;100 000 for the current rates of admission and lengths of hospital stay in Spain. CONCLUSIONS: Tiotropium was more effective than ipratropium and salmeterol as measured by objective clinical variables (forced expiratory volume in 1 second) and subjective ones (the Saint George's Respiratory Questionnaire and dyspnea transitional index). Hospital stays were shorter and exacerbations fewer with tiotropium. In all cases, tiotropium was more cost-effective than the alternatives, thus use of tiotropium could help hospitals to save money.

Análisis del coste-eficacia del tiotropio frente al ipratropio y salmeterol / Cost-effectiveness analysis of tiotropium compared to ipratropium and salmeterol

Objetivo: El incesante incremento de los costes en un marco en el que los recursos son limitados, así como la aparición de nuevos medicamentos más costosos y a la vez más eficaces, justifica la evaluación económica de los medicamentos. El objetivo de este trabajo es evaluar el coste-eficacia de uno de los fármacos más novedosos para el tratamiento de la enfermedad pulmonar obstructiva crónica (EPOC), el tiotropio. Material y método: Se ha realizado un análisis de coste-eficacia (costes y consecuencias) desde la perspectiva del Sistema Nacional de Salud. Las alternativas analizadas han sido ipratropio y salmeterol. Se han considerado sólo costes sanitarios directos en el ámbito hospitalario. Los parámetros de eficacia analizados han sido: volumen espiratorio forzado en el primer segundo, calidad de vida (mediante el Saint George's Respiratory Questionnaire), índice transicional de disnea, estancias medias y exacerbaciones. Dichos parámetros se han obtenido de las principales revisiones y ensayos clínicos aleatorizados publicados sobre el tiotropio. Resultados: Teniendo en cuenta la reducción del número de exacerbaciones conseguida con el tiotropio frente al ipratropio y salmeterol (el 37 y el 25%, respectivamente) y del número de días de estancia hospitalaria (el 33 y el 14%, respectivamente), su utilización puede suponer un ahorro superior a los 100.000 € para las cifras actuales de tasa de ingresos y días de estancia hospitalaria de los pacientes con EPOC en España. Conclusiones: El tiotropio ha sido más efectivo que el ipratropio y salmeterol tanto en parámetros clínicos (objetivos, como el volumen espiratorio forzado en el primer segundo, y subjetivos, como el Saint George's Respiratory Questionnaire y el índice transicional de disnea) como en disminución de estancias hospitalarias y exacerbaciones. En todos los casos resulta más coste-efectivo que sus alternativas, lo que supone importantes ahorros en el ámbito hospitalario

Objective: The constant increase in health care costs, in a context of limited resources and the appearance of more costly though more effective drugs, justifies an assessment of the pharmacoeconomics of these drugs. The objective of this study was to evaluate the cost-effectiveness of one of the newest drugs for the treatment of chronic obstructive pulmonary disease (COPD)-tiotropium. Material and method: A cost-effectiveness analysis (costs and outcomes) within the framework of the Spanish National Health System was done. The alternatives to tiotropium analyzed were ipratropium and salmeterol. Direct health care costs associated with hospital treatment were calculated. Forced expiratory volume in 1 second, quality of life (with the Saint George's Respiratory Questionnaire), dyspnea transitional index, mean stay in hospital, and exacerbations were the variables used to measure effectiveness. Values for these variables were taken from the main reviews and randomized clinical trials published for tiotropium. Results: For COPD patients, treatment with tiotropium leads to a greater reduction in exacerbations (37% compared to ipratropium and 25% compared to salmeterol 25%), and a reduction in the number of days in hospital (33% compared to ipratropium and 14% compared to salmeterol). Therefore, use of tiotropium could save €100 000 for the current rates of admission and lengths of hospital stay in Spain. Conclusions: Tiotropium was more effective than ipratropium and salmeterol as measured by objective clinical variables (forced expiratory volume in 1 second) and subjective ones (the Saint George's Respiratory Questionnaire and dyspnea transitional index). Hospital stays were shorter and exacerbations fewer with tiotropium. In all cases, tiotropium was more cost-effective than the alternatives, thus use of tiotropium could help hospitals to save money

Communication in general practice: differences between European countries.

BACKGROUND: Based on differences in national health care system characteristics such as the gatekeeping role of GPs (at the macrolevel) and on diverging GP and patient characteristics (at the microlevel), communication may differ between countries. Knowledge of the influence of these characteristics on doctor-patient communication will be important for setting European health care policies. OBJECTIVES: Our objectives were (i) to compare doctor-patient communication in general practice between European countries; and (ii) to investigate the influence of the gatekeeping system and GP and patient characteristics on doctor-patient communication in general practice. METHODS: Fifteen patients per GP (in total 2825 patients) of 190 GPs in six European countries were included. Participating countries were The Netherlands, Spain, the UK (gatekeeping countries), Belgium, Germany and Switzerland (non-gatekeeping countries). Data were collected by means of patient and GP questionnaires and observation of videotaped consultations, and analysed by one-way and multilevel, multivariate analysis. RESULTS: Differences in communication between countries were found in: affective and instrumental behaviour; biomedical and psychosocial talk; GPs' patient-directed gaze; and consultation length. The study showed that GPs' gatekeeping role (with registered patients) was less important for doctor-patient communication than was expected. Patient characteristics such as gender, age, having psychosocial problems, and familiarity between the doctor and the patient were the most important in explaining differences in communication. CONCLUSION: The gatekeeping role of GPs is hardly important in explaining doctor-patient communication. The relationship is more complex than expected. Patient and GP characteristics are more important. Cultural factors should be included in future studies.

[Correlation between subjective and objective health measurements in patients with chronic obstructive pulmonary disease (COPD)]. / Correlación entre medidas de salud subjetivas y objetivas en pacientes con enfermedad pulmonar obstructiva crónica (EPOC).

AIMS: Analyze the relation between objective health assessment (OHA) -Forced spirometry- and subjective health assessment (SHA) -quality of life- in patients with chronic obstructive pulmonary disease (COPD). Analyze the correlation between two different questionnaires to assess quality of life. DESIGN: Cross-sectional study. PARTICIPANTS: 278 patients with COPD (confidence level 95%) from two urban health centers. MAIN MEASUREMENTS: Personal interview. VARIABLES: quality of life (Nottingham Health Profile; St George Respiratory Questionnaire); sociodemographic profile; diagnose of COPD; comorbidity; recent spirometry. STATISTICAL ANALYSES: Descriptive statistics; test ji-squared, Kruskal-Wallis and the correlation coefficient. RESULTS: Age: 66,9 years; sex: 88% male. Quality of life scales (mean and confidence intervals): Nottingham Health Profile subscales (total score 100 points): energy 40 (35.6-44.4), pain 35.9 (32.3-39.5), emotional reactions 32.5 (29.4-38.6), sleep 41.9 (37.8-45.9), social isolation 15.3 (12.7-17.9), mobility 36.7 (33.9-39.5) and global score 33.4 (30.8-36). St George Respiratory Questionnaire subscales (total scores 100 points): impact 38.01 (35.08-40.18), activity 53.8 (50.2-57.4), symptoms 37.7 (35.2-40.3) and global score 40.0 (38.6-43.2). The correlation coefficients between the two questionnaires ranged between 0.12 (for the sleep and symptoms dimensions: p = 0.03) and 0.66 (for the mobility and activity dimensions; p < 0.0001). There is a positive lineal relation between the two questionnaires and the spirometric stages of COPD (measured by the maximum respiratory volume in the first second). CONCLUSIONS: We found a good correlation between the two quality of life questionnaires, but St George was more specific for respiratory illness. There is a mild-light correlation between objective and subjective health assessment in patients with COPD.

Correlación entre medidas de salud subjetivas y objetivas en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) / Correlation between subjective and objective health measurements in patientes with chronic obstructive pulmonary disea (COPD)

Objetivos. Analizar la relación entre medidas de salud objetivas (espirometría actual) y medidas de salud subjetivas (calidad de vida autopercibida). Evaluar la correlación entre 2 cuestionarios de valoración de calidad de vida. Diseño. Descriptivo, transversal. Emplazamiento. Dos centros de salud urbanos con programa de crónicos (subprograma de enfermedad pulmonar obstructiva crónica [EPOC]).Participantes. Un total de 278 pacientes diagnosticados de EPOC. Mediciones principales. Mediante entrevista personal se analizan las siguientes variables: calidad de vida autopercibida (perfil de salud de Nottingham; cuestionario respiratorio St. George; rangos de puntuación de subescalas 0-100 puntos; perfil sociodemográfico, diagnóstico de EPOC, antecedentes personales, espirometría actual. Resultados. Edad, 66,9 ñ 8,9 años; género, 88 por ciento varones. Los principales resultados de salud autopercibida fueron (medias e IC del 95 por ciento): perfil de salud de Nottingham: subescalas de energía, 40 (35,6-44,4); dolor, 35,9 (32,3-39,5); emotividad, 32,5 (29,438,6); sueño, 41,9 (37,8-45,9); social, 15,3 (12,7-17,9); movilidad, 36,7 (33,9-39,5), y total, 33,4 (30,8-36). Cuestionario de St.George: subescalas de impacto, 38,01 (35,0840,18); actividad, 53,8 (50,2-57,4) síntoma, 37,7 (35,2-40,3) y total, 40,9 (38,6-43,2).Los coeficientes de correlación entre ambos cuestionarios oscilaron entre 0,12 (para las dimensiones sueño y síntoma; p = 0,03) y 0,66 (entre las dimensiones de movilidad y actividad; p < 0,0001). Existe una relación lineal de tendencia positiva entre ambos cuestionarios y las categorías de valores (normal, leve, moderado y grave) del parámetro espirométrico, volumen espiratorio máximo en el primer segundo (p < 0,0001).Conclusiones. Encontramos una buena correlación entre ambos cuestionarios de salud autopercibida, siendo de mayor especificidad para patología respiratoria el St. George. Existe una correlación levemoderada entre las medidas de salud objetivas y subjetivas en los pacientes con EPOC en nuestro medio. (AU)

Salud autopercibida, apoyo social y familiar de los pacientes con enfermedad pulmonar obstructiva crónica / Quality of life, familiar and social network of patients with chronic obstructive pulmonary disease

Fundamentos: la EPOC es una enfermedad crónica e invalidante con gran repercusión en la calidad de vida del paciente así como en su dinámica familiar y social. La percepción por parte del paciente de sus limitaciones genera un sentimiento de baja autoestima que pone en peligro su posición ante la familia y la sociedad. Objetivos: describir características sociodemográficas y conocer en los pacientes con EPOC la calidad de vida autopercibida, el apoyo social con que cuentan y su dinámica familiar.Diseño: descriptivo transversal.Material y métodos: selección mediante muestreo consecutivo de 278 pacientes diagnosticados de EPOC. Mediante entrevista personal se recogió : perfil sociodemográfico, hábito tabáquico y antecedentes clínicos (comorbilidad), salud autopercibida (perfil de salud de Nottingham, NHP, y Cuestionario Respiratorio St George, SGRQ), apoyo social (Escala de Duke-Unc) y apoyo familiar (test de AP GAR familiar). Estadística descriptiva.Resultados: variables sociodemográficas: varones (88 por ciento), de 66,9ñ8,9 años, casados (87 por ciento), analfabetos (46,7 por ciento), jubilados (77 por ciento). Fumadores (76 por ciento) de 53,2 paquetes/año. Comorbilidad: 76 por ciento pacientes. Los principales resultados de salud autopercibida fueron (medias e IC 95 por ciento): perfil de Salud de Nottingham (0-100): subescalas de energía 40 (35,6-44,4), dolor 35,9 (32,3-39,5), emotividad 32,5 (29,4-38,6), sueño 41,9 (37,8-45,9), so cial 15,3 (12,7-17,9), movilidad 36,7 (33,9-39,5) y total 33,4 (30,8-36). Cuestionario de St. George (0-100): subescalas de impacto 38,01 (35,0840,18), actividad 53,8 (50,2-57,4), síntoma 37,7 (35,2-40,3) y total 40,9 (38,6-43,2). Apoyo social Conclusiones: la calidad de vida de los pacientes con EPOC resultó estar bastante alterada fundamentalmente en las dimensiones de sueño, energía y movilidad del NHP y en la subescala que valora la limitación de la actividad a causa de la disnea del SGRQ. Algo más de la mitad de los pacientes referían buen apoyo social, siendo mayor el afectivo que el confidencial. Consideramos importante el porcentaje de disfunción familiar (20,3 por ciento) (AU)