[Alveolar epithelial cell injury as an etiopathogenic factor in pulmonary fibrosis]

Cost analysis of chronic obstructive pulmonary disease (COPD): a systematic review

BACKGROUND

Chronic Obstructive Pulmonary Disease (COPD) is a treatable disease with a high prevalence, and high morbidity associated with significant socioeconomic costs.

OBJECTIVE

To carry out a systematic review of the literature to analyze the main cost studies associated with COPD, in order to determine the main factors that influence the costs of the disease.

METHODS

Searches were conducted in PubMed, SCOPUS and Web of Science databases for cost studies on COPD published in English, between the years 2015 and 2020. The search terms were "COPD" OR "pulmonary disease, chronic obstructive", "cost*" OR "cost of illness", "economic impact" AND "burden of disease". The inclusion criteria included the identification of reported cost of the disease, economic burden, medical care expenses or use resources for COPD, the methodology used, data sources, and variables studied.

RESULTS

18 publications were analyzed: 17 included direct health costs, 6 included direct non-medical costs, 12 analyzed indirect costs and two reported intangible costs. Most of the studies reported data for developed and European countries, with direct costs being the most studied. Trends were observed in multiple studies of direct and healthcare costs for European countries measured by patient and year, where the higher costs were associated with more severe COPD and a frequent history of exacerbations. The highest costs reported corresponded to hospitalizations and the associated pharmacological treatment. The importance of the loss of productivity and premature retirement within the profile of the COPD patient was also highlighted as the main generator of indirect costs of the disease.

CONCLUSION

COPD generates substantial costs for the health system, mainly related to moderate to severe stages and the exacerbations and complications entailed. It is important to strengthen health systems with monitoring, evaluation and health education models that allow these patients to remain stable to avoid decompensation and subsequent hospitalizations.

Potentially Inappropriate Prescriptions in Heart Failure with Reduced Ejection Fraction (PIP-HFrEF)

Heart failure (HF) is a chronic debilitating and potentially life-threatening condition. Heart Failure patients are usually at high risk of polypharmacy and consequently, potentially inappropriate prescribing leading to poor clinical outcomes. Based on the published literature, a comprehensive HF-specific prescribing review tool is compiled to avoid medications that may cause HF or harm HF patients and to optimize the prescribing practice of HF guideline-directed medical therapies. Recommendations are made in line with the last versions of ESC guidelines, ESC position papers, scientific evidence, and experts' opinions.

Development and Preliminary Evaluation of the Effects of an mHealth Web-Based Platform (HappyAir) on Adherence to a Maintenance Program After Pulmonary Rehabilitation in Patients With Chronic Obstructive Pulmonary Disease: Randomized Controlled Trial

Background

Pulmonary rehabilitation is one of the main interventions to reduce the use of health resources, and it promotes a reduction in chronic obstructive pulmonary disease (COPD) costs. mHealth systems in COPD aim to improve adherence to maintenance programs after pulmonary rehabilitation by promoting the change in attitude and behavior necessary for patient involvement in the management of the disease.

Objective

This study aimed to assess the effects of an integrated care plan based on an mHealth web-based platform (HappyAir) on adherence to a 1-year maintenance program applied after pulmonary rehabilitation in COPD patients.

Methods

COPD patients from three hospitals were randomized to a control group or an intervention group (HappyAir group). Patients from both groups received an 8-week program of pulmonary rehabilitation and educational sessions about their illness. After completion of the process, only the HappyAir group completed an integrated care plan for 10 months, supervised by an mHealth system and therapeutic educator. The control group only underwent the scheduled check-ups. Adherence to the program was rated using a respiratory physiotherapy adherence self-report (CAP FISIO) questionnaire. Other variables analyzed were adherence to physical activity (Morisky-Green Test), quality of life (Chronic Obstructive Pulmonary Disease Assessment Test, St. George’s Respiratory Questionnaire, and EuroQOL-5D), exercise capacity (6-Minute Walk Test), and lung function.

Results

In total, 44 patients were recruited and randomized in the control group (n=24) and HappyAir group (n=20). Eight patients dropped out for various reasons. The CAP FISIO questionnaire results showed an improvement in adherence during follow-up period for the HappyAir group, which was statistically different compared with the control group at 12 months (56.1 [SD 4.0] vs 44.0 [SD 13.6]; P=.004) after pulmonary rehabilitation.

Conclusions

mHealth systems designed for COPD patients improve adherence to maintenance programs as long as they are accompanied by disease awareness and patient involvement in management.

Trial Registration

ClinicalTrials.gov NCT04479930; https://clinicaltrials.gov/ct2/show/NCT04479930

Effectiveness of a psychoeducation group intervention conducted by primary healthcare nurses in patients with depression and physical comorbidity: study protocol for a randomized, controlled trial

BACKGROUND

Depressive disorders are the third leading cause of consultation in primary care, mainly in patients with chronic physical illnesses. Studies have shown the effectiveness of group psychoeducation in reducing symptoms in depressive individuals. Our primary aim is to evaluate the effectiveness of an intervention based on a psychoeducational program, carried out by primary care nurses, to improve the remission/response rate of depression in patients with chronic physical illness. Secondarily, to assess the cost-effectiveness of the intervention, its impact on improving control of the physical pathology and quality of life, and intervention feasibility.

METHODS/DESIGN

A multicenter, randomized, clinical trial, with two groups and one-year follow-up evaluation. Economic evaluation study.

SUBJECTS

We will assess 504 patients (252 in each group) aged > 50 years assigned to 25 primary healthcare centers (PHC) from Catalonia (urban, semi-urban, and rural). Participants suffer from major depression (Beck depression inventory: BDI-II 13-28) and at least one of the following: type 2 diabetes mellitus, chronic obstructive pulmonary disease, asthma, and/or ischemic cardiopathy. Patients with moderate/severe suicide risk or severe mental disorders are excluded. Participants will be distributed randomly into the intervention group (IG) and control (CG).

INTERVENTION

The IG will participate in the psychoeducational intervention: 12 sessions of 90 min, once a week led by two Primary Care (PC) nurses. The sessions will consist of health education regarding chronic physical illness and depressive symptoms.

MAIN MEASUREMENTS

Clinical remission of depression and/or response to intervention (BDI-II).

SECONDARY MEASUREMENTS

Improvement in control of chronic diseases (blood test and physical parameters), drug compliance (Morinsky-Green test and number of containers returned), quality of life (EQ-5D), medical service utilization (appointments and hospital admissions due to complications), and feasibility of the intervention (satisfaction and compliance). Evaluations will be blinded, and conducted at baseline, post-intervention, and 12 months follow-up.

DISCUSSION

Results could be informative for efforts to prevent depression in patients with a chronic physical illness.

TRIAL REGISTRATION

NCT03243799 (registration date August 9, 2017).

Systematic Review of Pain in Clinical Practice Guidelines for Management of COPD: A Case for Including Chronic Pain?

Chronic pain is highly prevalent and more common in people with chronic obstructive pulmonary disease (COPD) than people of similar age/sex in the general population. This systematic review aimed to describe how frequently and in which contexts pain is considered in the clinical practice guidelines (CPGs) for the broad management of COPD. Databases (Medline, Scopus, CiNAHL, EMbase, and clinical guideline) and websites were searched to identify current versions of COPD CPGs published in any language since 2006. Data on the frequency, context, and specific recommendations or strategies for the assessment or management of pain were extracted, collated, and reported descriptively. Of the 41 CPGs (English n = 20) reviewed, 16 (39%) did not mention pain. Within the remaining 25 CPGs, pain was mentioned 67 times (ranging from 1 to 10 mentions in a single CPG). The most frequent contexts for mentioning pain were as a potential side effect of specific pharmacotherapies (22 mentions in 13 CPGs), as part of differential diagnosis (14 mentions in 10 CPGs), and end of life or palliative care management (7 mentions in 6 CPGs). In people with COPD, chronic pain is common; adversely impacts quality of life, mood, breathlessness, and participation in activities of daily living; and warrants consideration within CPGs for COPD.

[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]

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.

Spanish Registry of Patients With Alpha-1 Antitrypsin Deficiency: Database Evaluation and Population Analysis

INTRODUCTION AND OBJECTIVE

REDAAT, the Spanish Registry of Patients with Alpha-1 Antitrypsin Deficiency, was set up in order to improve knowledge of this disease. This study is an evaluation of the registry and an analysis of its patient population.

METHODS

The registry has a database hosted on the website www.redaat.es. It collects clinical and functional data on patients with PiSZ, ZZ phenotypes and other rare variants.

RESULTS

Thanks to the collaboration of 124 physicians, the registry currently contains information on 511 individuals from 103 healthcare centers. Of these 511, 348 (74.2%) are Pi*ZZ homozygotes, and 100 (19.5%) are Pi*SZ heterozygotes. More cases are seen in tertiary level hospitals. A total of 81% of the cases have respiratory disease, and a lower proportion of AATD cases were detected by family screening or liver disease. Follow-up data are available for 45% of the cases, and 35% received alpha-1 antitripsin replacement therapy.

CONCLUSIONS

The REDAAT registry is a useful tool for obtaining quality information about this minority disease in routine clinical practice conditions, although it is difficult to obtain follow-up data, and the representativeness of the sample included cannot be determined.

External validation of multidimensional prognostic indices (ADO, BODEx and DOSE) in a primary care international cohort (PROEPOC/COPD cohort)

BACKGROUND

Due to the heterogeneous and systemic nature of the chronic obstructive pulmonary disease (COPD), the new guidelines are oriented toward individualized attention. Multidimensional scales could facilitate its proper clinical and prognostic assessment, but not all of them were validated in an international primary care cohort, different from the original ones used for model development. Therefore, our main aim is to assess the prognostic capacity of the ADO, BODEx and DOSE indices in primary care for predicting mortality in COPD patients and to validate the models obtained in subgroups of patients, classified by revised Global Initiative for Chronic Obstructive Lung Disease (2011) and updated Spanish Guideline (2014). Besides, we want to confirm that the prognostic capacity of all indices increases if the number of exacerbations is substituted by the interval between them and to assess the impact on health of the patient's lifestyle, social network and adherence to treatment.

METHODS

Design: External validation of scales, open and prospective cohort study in primary care.

SETTING

36 health centres in 6 European high, medium and low income countries.

SUBJECTS

477 patients diagnosed with COPD, captured in clinical visit by their General Practitioner/Nurse.

PREDICTORS

Detailed patient history, exacerbations, lung function test and questionnaires at baseline.

OUTCOMES

Exacerbations, all-cause mortality and specific mortality, within 5 years of recruitment.

ANALYSIS

Multivariate logistic regression and Cox regression will be used. Possible non-linear effect of the indices will be studied by using Structured Additive Regression models with penalised splines. Subsequently, we will assess different aspects of the regression models: discrimination, calibration and diagnostic precision. Clinical variables modulated in primary care and the interval between exacerbations will be considered and incorporated into the analysis.

DISCUSSION

The Research Agenda for General Practice/Family Medicine highlights that the evidence on predictive values of prognostic indices in primary care is scarce. A prospective cohort like that of PROEPOC/COPD provides good opportunities for research into COPD and make communication easier between family practitioners, nursing staff, pneumologists and other professionals, supporting a multi-disciplinary approach to the treatment of these patients.

TRIAL REGISTRATION

ISRCTN52402811 . Date: 15/01/2015. Prospectively registered.

[Respiratory infections in Emergencies]

Respiratory infections account for 63.8% of infections met. Of which a quarter are lower respiratory tract: acute bronchitis, exacerbation of COPD or bronchiectasis and pneumonia. Acute bronchitis usually of viral etiology and in immunocompetent patients without comorbidity treatment is symptomatic with analgesics and anti-inflammatories. The main cause of exacerbation of COPD is the respiratory infection. The indication of empirical antibiotic choice and it is based on clinical criteria, the severity of the underlying disease, the severity of the exacerbation and the presence of risk factors for infection with Pseudomonas aeruginosa. The community-acquired pneumonia (CAP) is the leading cause of death by infection. The use of prognostic severity scales (PSI or CURB-65) is recommended for deciding where treatment is started, the tests to be performed for the etiological diagnosis and the recommended empirical antibiotic therapy. Patients with Healthcare Associated Pneumonia (HCAP) and nosocomial pneumonia (NP) have a higher risk of infection by multiresistant microorganisms (MMR) and increased morbidity and mortality. It requires specific empirical treatment depending on the severity of disease and risk factors for infection MMR.

Short- and long-term effectiveness of a supervised training program in spirometry use for primary care professionals

INTRODUCTION

Despite the importance of spirometry, its use and quality are limited in the Primary Care setting. There are few accredited training programs that have demonstrated improvement in the quality of spirometric studies. In this paper, we analyze the short- and long-term effectiveness of a supervised training program for performing and interpreting spirometries.

METHODOLOGY

Ours is an intervention study with before and after measurements. The target population included teams of physicians and nursing staff at 26 health-care centers in the area of Vigo (Galicia, Spain). The structured training program involved 2 theoretical and practical training sessions (that were 2months apart), an intermediate period of 30 supervised spirometries performed in the respective centers and weekly e-mail exercises. Effectiveness was evaluated using exercises at the beginning (test 1) and the end (test 2) of the 1st day, 2nd day (test 3) and one year later (test 4), as well as the analysis of spirometries done in month1, month2 and one year later. Participants also completed a survey about their satisfaction.

RESULTS

74 participants initiated the program; 72 completed the program, but only 45 participated in the one-year evaluation. Mean test scores were: 4.1±1.9 on test 1; 7.5±1.6 on test 2; 8.9±1.3 on test 3, and 8.8±1.4 on test 4. During month1, the percentage of correctly done/interpreted tests was 71%, in month two it was 91% and after one year it was 83% (P<.05).

CONCLUSIONS

A training program based on theoretical and practical workshops and a supervised follow-up of spirometries significantly improved the ability of Primary Care professionals to carry out and interpret spirometric testing, although the quality of the tests diminished over time.