Expert opinion and patients' in-depth interviews on the impact of pulmonary complications in systemic sclerosis

OBJECTIVE

To qualitatively explore the perceptions and opinions of experts dealing with systemic sclerosis (SSc) and patients with SSc on the impact of the disease and pulmonary complications on economic status, psycho-social wellbeing and the diagnostic and therapeutic journey, and to identify which strategies/interventions may be useful to address patients' and their family's needs.

METHODS

An expert meeting was conducted using the NGT to discuss the consequences of pulmonary complications on the Italian SSc community. The direct experience of five patients with SSc and pulmonary complications was described through in-depth interviews conducted by psychologists.

RESULTS

The experts' meeting and patients' in-depth interviews underline the complexity of SSc and the consequences of pulmonary involvement on patients' and caregivers' health-related quality of life, working ability, psychological wellbeing and social interactions. Panellists suggest that improved communication between physicians, associations and institutions could help protect the working status of patients with SSc. Granting patients disability benefits, providing access to part-time jobs and productivity-focused training could also help decrease the economic burden of the disease. A multidisciplinary approach is recommended to reduce treatment burden, together with the implementation of standard diagnostic and therapeutic paths and increased use of telemedicine via platforms that ensure secure health data sharing. Both patients and caregivers may benefit from psychological support.

CONCLUSION

SSc and pulmonary fibrosis have profound consequences on patients' and caregivers' health-related quality of life, working ability, psychological wellbeing and social interactions. Some activities may help patients and families deal with these aspects of the disease.

Tele-Assisted Palliative Homecare for Advanced Chronic Obstructive Pulmonary Disease: A Feasibility Study

BACKGROUND

Despite real needs, very few chronic obstructive pulmonary disease (COPD) patients with life-limiting disease receive a well-organized support for palliative care (PC).

OBJECTIVE

To test the feasibility of, and patient satisfaction with, an advanced care plan for severe COPD patients followed by tele-assistance at home for six months that focused on monitoring patient's palliative topics through a dedicated checklist.

METHODS

Ten hospitalized patients with severe COPD (<1-year life expectancy) received a 60 minutes PC talk by a specialist to define an advanced care plan in the case of very severe respiratory insufficiency, based on three options: (1) endotracheal intubation (EI); (2) noninvasive ventilation; or (3) no mechanical aid; O₂ and drugs, for example, opiates. After the talk, patients expressed their personal choice. Following discharge home, patients received structured monthly telephone monitoring from specialized tutor nurses for six months on palliative topics. Patient's anxiety before and after talk, depression, quality of life, specialist's quality of communication, and customer satisfaction were evaluated.

RESULTS

The palliative talk was feasible and anxiety low during the talk. Nine out 10 patients were followed up by nurse till the end of the program. Overall bad days of life, negative emotions, and perception of disease deterioration were the palliative topics more frequently declared by patient during the phone calls. Two patients changed their preference from EI to O₂ therapy/sedation as a consequence of the intervention. Five out of 10 patients died. All patients expressed a high level of satisfaction of the service.

DISCUSSION

Tele-assisted PC is feasible and well accepted. According to these observations, a suitable supportive program can be the goal of a future study.

[A novel standard protocol of long-term follow-up shared with general practitioners after percutaneous coronary intervention: appropriateness and economic impact]

BACKGROUND

Follow-up modalities for patients undergoing percutaneous coronary intervention (PCI) are not well defined and standard protocols have been not established. The purpose of this study was to assess: a) the frequency and patterns of cardiology visits, echocardiographic examinations and stress tests after PCI in clinical practice; b) the impact of a multidisciplinary protocol of long-term follow-up after PCI shared with general practitioners on the appropriateness and reduction in healthcare costs.

METHODS

A total of 780 patients who underwent PCI in 2010 in two Italian hospitals were analyzed. The number of cardiological examinations (total, routine and clinically driven) performed during 2 years of follow-up were recorded and stratified according to the patient's risk profile. The latter was defined according to the multidisciplinary protocol. In addition, a simulation of the spread between provided and necessary tests (according to the multidisciplinary protocol) was carried out.

RESULTS

The mean number of cardiological examinations per patient provided during follow-up was 5, of which 4.4 were routine tests in asymptomatic patients. Routine tests were performed more frequently in patients at low risk compared to those at higher risk. By applying the multidisciplinary protocol to the case mix and by merging clinical visit and stress test or echocardiographic examination, a reduction of 0.87 tests per patient/year would be expected. This reduction would result in a 39% decrease in follow-up examinations in this specific clinical setting.

CONCLUSIONS

This observational study demonstrates that unnecessary cardiological clinical and functional tests are often performed in long-term follow-up of patients submitted to PCI. The application of a standard protocol of follow-up shared with general practitioners may help avoiding unnecessary consultations, thus reducing healthcare costs.

Structured management strategy based on the Gastro-oesophageal Reflux Disease (GERD) Questionnaire (GerdQ) vs. usual primary care for GERD: pooled analysis of five cluster-randomised European studies

BACKGROUND

Response to treatment among primary care patients with gastro-oesophageal disease (GERD) is variable.

AIM

The GERD Management Project (GMP) evaluated the effectiveness of a structured management approach to GERD vs. standard treatment (usual care).

METHODS

Data from five cluster-randomised clinical trials in adult primary care patients with symptoms of GERD were pooled. The structured pathway was based on the self-administered GERD Questionnaire (GerdQ) and was compared with standard treatment.

RESULTS

1734 patients were enrolled (structured treatment, n=834; standard treatment, n=900). The difference in the mean GerdQ score change from baseline favoured the structured pathway (-0.61; 95% CI: -0.88, -0.34; p<0.001). The odds ratio for an indication for treatment revision at the end of follow-up (structured vs. standard treatment) was 0.39 (95% CI: 0.29, 0.52; p=0.001).

CONCLUSIONS

Management of primary care patients with GERD can be improved by systematic stratification of patients using a patient management tool such as the GerdQ.

Structured management strategy versus usual care for gastroesophageal reflux disease: rationale for pooled analysis of five European cluster-randomized trials

BACKGROUND

Gastroesophageal reflux disease (GERD) has a major impact at the primary care level and there is a need to evaluate whether the diagnosis and therapeutic management of GERD in Europe needs to be improved.

METHODS

This project was designed to test the hypothesis that a new primary care management strategy would improve outcomes for patients with GERD, compared with usual care, in Europe. The analysis pools five separate cluster-randomized studies conducted in Austria, Italy, Norway, Spain and Sweden. These studies used a strategy based on the self-administered GerdQ questionnaire to stratify adult patients with symptoms of heartburn or regurgitation according to the frequency and impact of symptoms. A score of ≥8 indicates a high probability of suffering GERD. Patients with a GerdQ impact score ≤2 were treated with generic proton-pump inhibitors according to local guidance, and patients with an impact score ≥3 were treated with esomeprazole 40 mg once daily.

RESULTS

In total, 2400 patients were enrolled across the five studies. The protocols were modified by individual countries according to their local guidelines/requirements. In Norway, the new management strategy was compared with traditional routine endoscopy and 24-hour pH-metry, and encompassed proton-pump inhibitor reimbursement restrictions. Outcome measures differed by country, but included control of GERD symptoms, self-rated health status and work productivity, treatment changes, specialist referrals and physician adherence. GERD-related use of healthcare resources was also evaluated.

CONCLUSION

The pooled analysis will determine whether a locally adapted primary care management strategy for GERD, using GerdQ as a patient-tailored diagnostic and therapeutic evaluation tool, is beneficial compared with usual care across five countries with different standard approaches to GERD management and control.

Prevalence of systemic sclerosis in Valtrompia in northern Italy. A collaborative study of rheumatologists and general practitioners

OBJECTIVE

To evaluate the prevalence of patients with Systemic Sclerosis (SSc) in Valtrompia in northern Italy.

METHODS

Patients were recruited from the records of 28 general practitioners (GPs) whose practices covered 38,348 individuals aged over 14 years, and from a public Hospital database covering all patients evaluated in community clinics, day-hospitals and inpatient units of the area. Crossing data from the two sources revealed a 100% concordance. Rheumatological re-evaluation confirmed a diagnosis of SSc in 13 patients (11 female, 2 male; 2 diffuse SSc, 11 limited SSc), fulfilling ACR criteria in 10 cases and Le-Roy-Medsger 2001 criteria in 3 further cases.

RESULTS

Prevalence of SSc was estimated at 33.9 cases among 100,000 adults aged over 14 years (95% confidence intervals: 15.5-52.3).

CONCLUSION

This rather high prevalence reflects both changes in the diagnostic criteria for SSc including milder forms of disease, and recruitment of these mild cases due to active collaboration between GPs and specialists.

[Peer review about gastro-esophageal reflux disease in primary care: epidemiology, diagnostic and therapeutic management]

Retrospective research carried out by 29 General Practitioners in their databases, in order to evaluate the prevalence of gastro-esophageal reflux disease in its different clinical outbreaks and the incidence of new diagnosis in the last quinquennium, the diagnostic approach through instrumental examinations (endoscopy) or empirical tests (PPI test), and the therapeutical aspects, in particular concerning the usage of PPI. The prevalence has been of 3.82%, while the data concerning the incidence have pointed out a progressive increase of the diagnosis in the last quinquennium, specially for the atypical outbreaks. Moreover, it has been noted a likely excessive use of endoscopy, in the follow up as well, while less used is the IPP test. Gastroesophageal reflux disease is the most important item in the expenditure for the usage of IPP.