Population-based analysis of patients with COPD in Catalonia: a cohort study with implications for clinical management

BACKGROUND: Clinical management of patients with chronic obstructive pulmonary disease (COPD) shows potential for improvement provided that patients' heterogeneities are better understood. The study addresses the impact of comorbidities and its role in health risk assessment. OBJECTIVE: To explore the potential of health registry information to enhance clinical risk assessment and stratification. DESIGN: Fixed cohort study including all registered patients with COPD in Catalonia (Spain) (7.5 million citizens) at 31 December 2014 with 1-year (2015) follow-up. METHODS: A total of 264 830 patients with COPD diagnosis, based on the International Classification of Diseases (Ninth Revision) coding, were assessed. Performance of multiple logistic regression models for the six main dependent variables of the study: mortality, hospitalisations (patients with one or more admissions; all cases and COPD-related), multiple hospitalisations (patients with at least two admissions; all causes and COPD-related) and users with high healthcare costs. Neither clinical nor forced spirometry data were available. RESULTS: Multimorbidity, assessed with the adjusted morbidity grouper, was the covariate with the highest impact in the predictive models, which in turn showed high performance measured by the C-statistics: (1) mortality (0.83), (2 and 3) hospitalisations (all causes: 0.77; COPD-related: 0.81), (4 and 5) multiple hospitalisations (all causes: 0.80; COPD-related: 0.87) and (6) users with high healthcare costs (0.76). Fifteen per cent of individuals with highest healthcare costs to year ratio represented 59% of the overall costs of patients with COPD. CONCLUSIONS: The results stress the impact of assessing multimorbidity with the adjusted morbidity grouper on considered health indicators, which has implications for enhanced COPD staging and clinical management

Guía metodológica para la elaboración de un programa estructurado de educación terapéutica: del diseño a la evaluación

Antecedentes y objetivo: La educación terapéutica (ET) se ha demostrado eficaz e imprescindible en un contexto de prevalencia creciente de enfermedades crónicas, siendo necesarias herramientas para la planificación de programas estructurados. El objetivo fue elaborar una guía para el diseño y evaluación de un programa de educación terapéutica. Métodos: 1) Se constituyó un grupo multidisciplinario de profesionales expertos, procedentes de distintas áreas hospitalarias. 2) Se realizó una revisión exhaustiva de la literatura científica sobre la planificación de programas de ET dirigidos a personas con diferentes enfermedades crónicas, familiares o cuidadores. 3) El texto final propuesto se sometió a comentarios y sugerencias de profesionales del centro directamente implicados en actividades educativas y participantes en un curso sobre metodología de Información y Educación Terapéutica. Las recomendaciones fueron consensuadas por el grupo redactor. Resultados Se obtuvo un procedimiento normalizado de trabajo dirigido a los profesionales implicados en la planificación de programas estructurados de ET, basado en recomendaciones internacionales. El documento está estructurado en los siguientes apartados: a) Definición del problema de salud y análisis de la situación. b) Estructura del programa: recursos humanos y materiales; objetivos: de salud, de conducta y educativos y metodología. c) Circuito que sigue el paciente y familia/cuidador en el programa. d) Evaluación e indicadores. La evaluación del procedimiento, en el marco de los cursos de metodología, fue favorable. Conclusiones: La metodología aportada por este documento servirá de instrumento para planificar de forma homogénea y sistematizada los programas educativos, unificando criterios en la redacción de los programas

Protocol for regional implementation of collaborative lung function testing

The potential of forced spirometry (FS) testing for diagnosis, monitoring and management of chronic respiratory patients is well established1-3 such that FS is a pivotal test in both respiratory medicine and primary care. Moreover, it also shows potential in the informal care scenario: that is, in pharmacy offices for case-finding purposes4,5 and for self-management in selected patients.6,7 We acknowledge that well-designed studies8 have failed to show practical benefits of FS for asthma and COPD diagnosis and management in primary care. However, it has been demonstrated that historical limitations for extensive use of FS in primary care, because of suboptimal quality of testing, can be overcome by offline remote support by specialised professionals.9,10 Large-scale deployment of this type of setting has generated evidence of cost-effectiveness.

Patient Experience in Pancreas-Kidney Transplantation-A Methodological Approach Towards Innovation in an Established Program

Simultaneous pancreas-kidney transplantation (SPKT) leads to increased survival and quality of life, and is an alternative treatment for insulin-dependent diabetes mellitus and end-stage kidney disease. Due to the particularities of this population (often with multiple comorbidities) and of the surgery (only performed in a few centers), a comprehensive analysis of patients' experience along the SPKT process is crucial to improve patient care and add value to this procedure. Therefore, we applied a systematic and iterative methodology with the participation of both patients and professional teams working together to explore and identify unmet needs and value-adding steps along the transplant patient journey at an established pancreas transplant program. Four main steps (to comprehend, to explore, to experiment and to assess) led to several interventions around three major areas: Administration and logistics, information and communication, and perceived quality of assistance. As a result, both displacements to the hospital for diagnostic purposes and the time delay involved in joining the patient waiting list for transplantation were reduced in parallel to the administrative procedures. In conclusion, the methodological implementation of key organizational changes has great impact on overall patient experience. Further quantitative analysis from the patient's perspective will consolidate our program and may add new prototype service design components

Personalized Respiratory Medicine: Exploring the Horizon, Addressing the Issues. Summary of a BRN-AJRCCM Workshop Held in Barcelona on June 12, 2014.

This Pulmonary Perspective summarizes the content and main conclusions of an international workshop on personalized respiratory medicine coorganized by the Barcelona Respiratory Network (www.brn.cat)and the AJRCCM in June 2014. It discusses (1) its definition and historical, social, legal, and ethical aspects; (2) the view from different disciplines, including basic science, epidemiology, bioinformatics,and network/systems medicine; (3) the bottlenecks and opportunities identified by some currently ongoing projects; and (4) the implications for the individual, the healthcare system and the pharmaceutical industry. The authors hope that, although it is not a systematic review on the subject,this document can be a useful reference for researchers, clinicians, healthcare managers, policy-makers,and industry parties interested in personalized respiratory medicine

Standardizing admission and discharge processes to improve patient flow: A cross sectional study

Background: The aim of this study was to evaluate how hospital capacity was managed focusing on standardizing the admission and discharge processes. Methods: This study was set in a 900-bed university affiliated hospital of the National Health Service, near Barcelona (Spain). This is a cross-sectional study of a set of interventions which were gradually implemented between April and December 2008. Mainly, they were focused on standardizing the admission and discharge processes to improve patient flow. Primary administrative data was obtained from the 2007 and 2009 Hospital Database. Main outcome measures were median length of stay, percentage of planned discharges, number of surgery cancellations and median number of delayed emergency admissions at 8:00 am. For statistical bivariate analysis, we used a Chi-squared for linear trend for qualitative variables and a Wilcoxon signed ranks test and a Mann-Whitney test for non-normal continuous variables. Results: The median patients' global length of stay was 8.56 days in 2007 and 7.93 days in 2009 (p < 0.051). The percentage of patients admitted the same day as surgery increased from 64.87% in 2007 to 86.01% in 2009 (p < 0.05). The number of cancelled interventions due to lack of beds was 216 patients in 2007 and 42 patients in 2009. The median number of planned discharges went from 43.05% in 2007 to 86.01% in 2009 (p < 0.01). The median number of emergency patients waiting for an in-hospital bed at 8:00 am was 5 patients in 2007 and 3 patients in 2009 (p < 0.01). Conclusions: In conclusion, standardization of admission and discharge processes are largely in our control. There is a significant opportunity to create important benefits for increasing bed capacity and hospital throughput

Desarrollo de un marco conceptual para la evaluación de la atención a la cronicidad en el Sistema Nacional de Salud

ABSTRACT The aim was to develop a conceptual framework for the assessment of new healthcare initiatives on chronic diseases within the Spanish National Health System. A comprehensive literature review between 2002 and 2013, including systematic reviews, meta-analysis, and reports with evaluation frameworks and/or assessment of initiatives was carried out; integrated care initiatives established in Catalonia were studied and described; and semistructured interviews with key stakeholders were performed. The scope and conceptual framework were defined by using the brainstorming approach. Of 910 abstracts identified, a total of 116 studies were included. They referred to several conceptual frameworks and/or assessment indicators at a national and international level. An overall of 24 established chronic care initiatives were identified (9 integrated care initiatives); 10 in-depth interviews were carried out. The proposed conceptual framework envisages: 1)the target population according to complexity levels; 2)an evaluation approach of the structure, processes, and outcomes considering the health status achieved, the recovery process and the maintenance of health; and 3)the dimensions or attributes to be assessed. The proposed conceptual framework will be helpful develop indicators and implement them with a community-based and result-oriented approach and a territorial or population-based perspective within the Spanish Health System. This will be essential to know which are the most effective strategies, what are the key elements that determine greater success and what are the groups of patients who can most benefit.RESUMEN El objetivo del trabajo fue desarrollar un marco conceptual para la evaluación de nuevos programas de gestión clínica y asistencial de carácter integrado en el Sistema Nacional de Salud para la atención a las personas con enfermedades crónicas. Se realizó una revisión exhaustiva de la literatura entre 2002-2013 incluyendo revisiones sistemáticas, metaanálisis e informes con modelos de evaluación y/o evaluaciones de programas. Se estudiaron y describieron programas locales de atención a la cronicidad implementados en Cataluña y se realizaron entrevistas semiestructuradas con expertos clave en el ámbito catalán. El alcance y el marco conceptual se definieron mediante la técnica del brainstorming. De 910 resúmenes identificados, se incluyeron 116 documentos que se referían a marcos conceptuales e indicadores de evaluación a nivel español e internacional. Se identificaron 24 programas de atención a la cronicidad (9 de carácter integrado). El marco conceptual propuesto contempló: 1) la población diana según niveles de complejidad; 2) un enfoque de evaluación de la estructura, procesos y resultados teniendo en cuenta el estado de salud conseguido, el proceso de recuperación y mantenimiento de la salud; y 3) las dimensiones o atributos que se deben evaluar. El marco conceptual propuesto permitirá desarrollar indicadores e implementarlos con un enfoque comunitario, orientados a los resultados y tener una visión territorial o poblacional, que será imprescindible para saber cuál es la estrategia más efectiva, cuáles son los elementos que determinan un mayor éxito y cuáles son los grupos de pacientes que más se pueden beneficiar

Performance of mechanical ventilators at the patient's home: a multicentric quality control study

Background: Quality control procedures vary considerably among the providers of equipment for home mechanical ventilation (HMV). Methods: A multicentre quality control survey of HMV was performed at the home of 300 patients included in the HMV programmes of four hospitals in Barcelona. It consisted of three steps: (1) the prescribed ventilation settings, the actual settings in the ventilator control panel, and the actual performance of the ventilator measured at home were compared; (2) the different ventilator alarms were tested; and (3) the effect of differences between the prescribed settings and the actual performance of the ventilator on non-programmed readmissions of the patient was determined. Results: Considerable differences were found between actual, set, and prescribed values of ventilator variables; these differences were similar in volume and pressure preset ventilators. The percentage of patients with a discrepancy between the prescribed and actual measured main ventilator variable (minute ventilation or inspiratory pressure) of more than 20% and 30% was 13% and 4%, respectively. The number of ventilators with built in alarms for power off, disconnection, or obstruction was 225, 280 and 157, respectively. These alarms did not work in two (0.9%), 52 (18.6%) and eight (5.1%) ventilators, respectively. The number of non-programmed hospital readmissions in the year before the study did not correlate with the index of ventilator error. Conclusions: This study illustrates the current limitations of the quality control of HMV and suggests that improvements should be made to ensure adequate ventilator settings and correct ventilator performance and ventilator alarm operation

Protocol for regional implementation of collaborative lung function testing

The potential of forced spirometry (FS) testing for diagnosis, monitoring and management of chronic respiratory patients is well established1-3 such that FS is a pivotal test in both respiratory medicine and primary care. Moreover, it also shows potential in the informal care scenario: that is, in pharmacy offices for case-finding purposes4,5 and for self-management in selected patients.6,7 We acknowledge that well-designed studies8 have failed to show practical benefits of FS for asthma and COPD diagnosis and management in primary care. However, it has been demonstrated that historical limitations for extensive use of FS in primary care, because of suboptimal quality of testing, can be overcome by offline remote support by specialised professionals.9,10 Large-scale deployment of this type of setting has generated evidence of cost-effectiveness.