Proyecto INCLIASMA fase II - Inercia clínica en asma en España / INCLIASMA phase II project – Clinical inertia in asthma in Spain

Objetivos El 80% de los pacientes con asma están mal controlados. A pesar de disponer de guías de práctica clínica (GPC) actualizadas, se sigue detectando un deficiente control y tratamiento del asma. El objetivo principal del estudio INCLIASMA faseII (INercia CLInica en ASMA) es analizar la realidad en el manejo del asma en las consultas de atención primaria (AP) españolas. Como objetivo secundario se planteó establecer una serie de recomendaciones clave en el manejo del paciente con asma, basadas en las conclusiones de los panelistas. Material y métodos Estudio transversal descriptivo, multicéntrico y no aleatorizado, que se desarrolló en dos rondas, siguiendo la metodología Delphi. Se elaboró un cuestionario on line específico para el proyecto de 41 ítems y divido en 5 bloques (diagnóstico, control, adherencia, tratamiento y criterios de derivación) y se pidió a un grupo de médicos de AP expertos en asma que expresaran su nivel de acuerdo o desacuerdo con el conjunto de ítems del cuestionario. De los resultados se identificaron las principales controversias existentes en el manejo de asma en España y se elaboraron recomendaciones prácticas. Resultados Participaron 24 panelistas. Hubo un consenso final en el 92,68% (38/41) de la totalidad de los ítems recogidos en el cuestionario. Los panelistas concluyeron que se tarda en exceso en diagnosticar el asma, existiendo un porcentaje elevado de pacientes asmáticos sin un correcto tratamiento, y, por ende, sin un adecuado control. La falta de tiempo, la sobrecarga asistencial o la inercia terapéutica son algunos de los factores determinantes de esta situación. Conclusione El estudio INCLIASMA faseII pone de relieve las controversias encontradas en la práctica clínica habitual en el manejo del asma, poniendo de manifiesto la necesidad continuada de formación y ofreciendo recomendaciones consensuadas que buscan mejorar el manejo de asma en nuestro país (AU)

Objectives Eighty percent of patients with asthma are poorly controlled. Despite the availability of updated clinical practice guidelines, poor asthma control and treatment continue to be detected. The main objective of the INCLIASMA phaseII study (INercia CLInica en ASMA) is to analyze the reality of asthma management in Spanish primary care (PC) clinics. As a secondary objective, it was proposed to establish a series of key recommendations in the management of patients with asthma, based on the conclusions of the panelists. Material and methods Cross-sectional descriptive, multicenter and non-randomized study, which was developed in two rounds, following the Delphi methodology. A specific online questionnaire was developed for the project with 41 items and divided into 5 blocks (diagnosis, control, adherence, treatment and referral criteria) and a group of PC physicians who were experts in asthma were asked to express their level of agreement or disagreement with the set of items in the questionnaire. From the results, the main existing controversies in the management of asthma in Spain were identified and practical recommendations were elaborated. Results Twenty-four panelists participated. There was a final consensus in 92.68% (38/41) of all the items collected in the questionnaire. The panelists concluded that it takes too long to diagnose asthma, and there is a high percentage of asthmatic patients without proper treatment, and therefore, without adequate control. Lack of time, care overload or therapeutic inertia are some of the determining factors in this situation. Conclusions The INCLIASMA phaseII study highlights the controversies found in routine clinical practice in asthma management, highlighting the continued need for training and offering consensus recommendations that seek to improve asthma management in our country (AU)

[INCLIASMA phase II project - Clinical inertia in asthma in Spain]. / Proyecto INCLIASMA fase II - Inercia clínica en asma en España.

OBJECTIVES: Eighty percent of patients with asthma are poorly controlled. Despite the availability of updated clinical practice guidelines, poor asthma control and treatment continue to be detected. The main objective of the INCLIASMA phaseII study (INercia CLInica en ASMA) is to analyze the reality of asthma management in Spanish primary care (PC) clinics. As a secondary objective, it was proposed to establish a series of key recommendations in the management of patients with asthma, based on the conclusions of the panelists. MATERIAL AND METHODS: Cross-sectional descriptive, multicenter and non-randomized study, which was developed in two rounds, following the Delphi methodology. A specific online questionnaire was developed for the project with 41 items and divided into 5 blocks (diagnosis, control, adherence, treatment and referral criteria) and a group of PC physicians who were experts in asthma were asked to express their level of agreement or disagreement with the set of items in the questionnaire. From the results, the main existing controversies in the management of asthma in Spain were identified and practical recommendations were elaborated. RESULTS: Twenty-four panelists participated. There was a final consensus in 92.68% (38/41) of all the items collected in the questionnaire. The panelists concluded that it takes too long to diagnose asthma, and there is a high percentage of asthmatic patients without proper treatment, and therefore, without adequate control. Lack of time, care overload or therapeutic inertia are some of the determining factors in this situation. CONCLUSIONS: The INCLIASMA phaseII study highlights the controversies found in routine clinical practice in asthma management, highlighting the continued need for training and offering consensus recommendations that seek to improve asthma management in our country.

Enfermedad pulmonar obstructiva crónica: morbimortalidad e impacto sanitario / Chronic obstructive pulmonary disease: Morbimortality and healthcare burden

La enfermedad pulmonar obstructiva crónica (EPOC) constituye un problema de salud pública de enorme y creciente importancia por su alta prevalencia, elevada morbimortalidad y costes socioeconómicos. Diversos estudios epidemiológicos españoles cifran la prevalencia en un 10% de la población adulta, pareciendo haberse estabilizado su crecimiento. Con todo, el infradiagnóstico sigue superando el 75%. El diagnóstico en fases de obstrucción leve y moderada se asocia a mayor supervivencia y menores costes (14 años y 9.730 D ), frente a los 10 años de supervivencia y 43.785 D de los pacientes diagnosticados en fases de obstrucción grave. La EPOC constituyó la cuarta causa de mortalidad en España en 2011, si bien las tasas de mortalidad ajustadas han disminuido en la última década más de un 20%, sobre todo en varones. Los pacientes con EPOC avanzada fallecen de la misma, pero los pacientes con EPOC leve o moderada lo hacen por enfermedades cardiovasculares o cáncer (sobre todo de pulmón). Se estima que el coste anual de la enfermedad alcanza los 3.000 millones de euros al año. Estos aumentan con la gravedad espirométrica y se asocian fundamentalmente con las agudizaciones (casi un 60% de los costes directos). La comorbilidad, entendida como la presencia de dolencias que coexisten con la enfermedad de estudio, es mayor en los pacientes con EPOC que en la población general, y condiciona resultados en salud (AU)

Chronic obstructive pulmonary disease (COPD) is an enormous public health problem and of growing importance due to its high prevalence, elevated morbimortality, and socioeconomic costs. Many Spanish epidemiological studies report a prevalence of 10% of the adult population, with its growth appearing to have stabilised. Nevertheless, over 75% of cases are still underdiagnosed. The diagnosis of mild and moderate obstruction is associated with a higher survival and lower costs (14 years and D 9,730) compared to 10 years survival and D 43,785 of patients diagnosed in the severe obstruction phase. COPD was the fourth cause of death in Spain in 2011, although the adjusted mortality rates have decreased more than 20% in the last decade, particularly in males. Patients with advanced COPD die from it, but patients with mild or moderate COPD die due to cardiovascular diseases or cancer (mainly of the lung). It is estimated that the annual cost of the disease is around 3,000 million Euros. These increase with the spirometric severity, and is mainly associated with exacerbations (almost 60% of the direct costs). Comorbidity, that is the presence of diseases that coexist with the studied disease, is higher in patients with COPD than in the general population and affects health results. © 2013 Sociedad Española de Médicos de Atención Primaria (SEMERGEN). Published by Elsevier España, S.L. All rights reserved (AU)

[Chronic obstructive pulmonary disease: Morbimortality and healthcare burden]. / Enfermedad pulmonar obstructiva crónica: morbimortalidad e impacto sanitario.

Chronic obstructive pulmonary disease (COPD) is an enormous public health problem and of growing importance due to its high prevalence, elevated morbimortality, and socioeconomic costs. Many Spanish epidemiological studies report a prevalence of 10% of the adult population, with its growth appearing to have stabilised. Nevertheless, over 75% of cases are still underdiagnosed. The diagnosis of mild and moderate obstruction is associated with a higher survival and lower costs (14 years and €9,730) compared to 10 years survival and €43,785 of patients diagnosed in the severe obstruction phase. COPD was the fourth cause of death in Spain in 2011, although the adjusted mortality rates have decreased more than 20% in the last decade, particularly in males. Patients with advanced COPD die from it, but patients with mild or moderate COPD die due to cardiovascular diseases or cancer (mainly of the lung). It is estimated that the annual cost of the disease is around 3,000 million Euros. These increase with the spirometric severity, and is mainly associated with exacerbations (almost 60% of the direct costs). Comorbidity, that is the presence of diseases that coexist with the studied disease, is higher in patients with COPD than in the general population and affects health results.

A home telehealth program for patients with severe COPD: the PROMETE study.

BACKGROUND: Acute exacerbations of chronic obstructive pulmonary disease (AECOP) are key events in the natural history of the disease. Patients with more AECOPD have worse prognosis. There is a need of innovative models of care for patients with severe COPD and frequent AECOPD, and Telehealth (TH) is part of these programs. METHODS: In a cluster assignment, controlled trial study design, we recruited 60 patients, 30 in home telehealth (HT) and 30 in conventional care (CC). All participants had a prior diagnosis of COPD with a post-bronchodilator forced expiratory volume (FEV1)% predicted <50%, age ≥ 50 years, were on long-term home oxygen therapy, and non-smokers. Patients in the HT group measured their vital signs on a daily bases, and data were transmitted automatically to a Clinical Monitoring Center for followed-up, and who escalated clinical alerts to a Pneumologist. RESULTS: After 7-month of monitoring and follow-up, there was a significant reduction in ER visits (20 in HT vs. 57 in CC), hospitalizations (12 vs. 33), length of hospital stay in (105 vs. 276 days), and even need for non-invasive mechanical ventilation (0 vs. 8), all p < 0.05. Time to the first severe AECOPD increased from 77 days in CC to 141 days in HT (K-M p < 0.05). There was no study withdrawals associated with technology. All patients showed a high level of satisfaction with the HT program. CONCLUSIONS: We conclude that HT in elderly, severe COPD patients with multiple comorbidities is safe and efficacious in reducing healthcare resources utilization.

Photobehavior of merocyanine 540 bound to human serum albumin.

The photobehavior of merocyanine 540 (MC) was studied in homogeneous media (ethanol, buffer and glycerol), and in microheterogenous systems (Triton X-100 micelles and in the presence of human serum albumin) using stationary and time-resolved techniques. Merocyanine 540 in aqueous solution mostly forms aggregates, which in the presence of Triton X-100 or HSA are disaggregated. The extent of binding to HSA and its characteristics were estimated from dye absorption and fluorescence changes following protein addition; the Trp-214 fluorescence quenching was also employed to assess the extent of dye association, and physical separation was employed to evaluate the dye's apparent association constant. These results showed that dye adsorption on HSA takes place at both main protein-binding sites (I and II). This adsorption leads to dye monomerization, changing its photobehavior remarkably, with a noticeable increase in fluorescence and triplet lifetimes. These slower decays can be ascribed to a reduction of the dye photoisomerization rate. In addition, the adsorption of the dye partially protects it from the oxygen present in solution, thus reducing the apparent dye triplet-quenching rate constant. However, singlet oxygen and MC triplet quantum yields remain very low in all the systems tested. Finally, we found that the photoconsumption of merocyanine bound to HSA takes place predominantly by a type I mechanism, being more than seven times more efficient than that taking place in ethanol.

Competencia clínica de los médicos de familia en 14 Comunidades Autónomas españolas / Clinical competence of the general practitioners in 14 Spanish Different Communities

Fundamento y Objetivo: El Desarrollo Profesional Continuo (DPC) es un proceso de adquisición, mantenimiento y mejora de conocimientos, habilidades, actitudes y competencia profesional. En España, mantener la competencia es responsabilidad del profesional, para ello debe detectar objetivamente sus déficts formativos. Este estudio, pretende detectar diferencias en niveles de competencia clínica y déficits formativos, entre médicos de familia de distintas CC.AA. españolas, en el año 2005. Sujetos y método: Estudio descriptivo transversal. Se evaluaron 1158 médicos de 14 CCAA. Se utilizó como herramienta la Evaluación de Competencia Objetiva Estructurada (ECOE) de 15 estaciones. Se compararon las puntuaciones globales obtenidas, por competencias y área de conocimiento mediante ANOVA, y se estudió la fiabilidad de la prueba, mediante el alfa de Cronbach. Resultados: La puntuación global media fue 59,08 (DE 6,12), (IC 95%: 58,52-59,31). Se detectaron diferencias significativas entre Cataluña (63,65±5,2) y Castilla-León (55,37±5,78), Valencia (57,20±7,18), Andalucía (57,67±6,04), y Murcia (57,19±5,50). Por componente competencial, el mejor resultado correspondió al área de comunicación (80,11% del ideal) y el peor a atención familiar (45,54%). Por áreas de conocimiento, el mayor se obtuvo en dolor abdominal (75,94±14,70) y el menor en diabetes (43,36±15.97). El coeficiente de fiabilidad global de la prueba, alfa de Cronbach, fue 0,79. Conclusiones: Este estudio muestra el mapa competencial de los médicos de familia españoles y las diferencias existentes entre CCAA. La competencia es globalmente buena. Este tipo de estudio aporta una visión integral al médico de familia sobre su DPC, que le servirá de guía en su formación, para conseguir la excelencia profesional y mantenerla (AU)

Objective: The Continuous Professional Development (CPD) is a process of acquisition, maintenance and improvement of knowledge, abilities, attitudes and professional competence. In Spain, the manteinance of the clinical competence is responsibility of the professional. The professional for it must detect his déficts of formation objectively. This study detects differences in levels of clinical competence and deficits of formation in general practitioners of different Spanish Communities, in 2005. Method: Cross sectional study. 1158 doctors of 14 Communities were evaluated. The Objective Structured Clinical Examination (OSCE) was used as a tool with 15 different clinical situations. The global scores were compared. By competitions and area of knowledge by means of ANOVA. The reliability of the test was assessed of alpha Cronbach. Results: The global score average was 59.08 (SD 6,12)(IC 95 58,52-59,31). Significant differences were detected between Cataluña (63,65 SD 5,2) and Castilla Leon (55,37 SD 5,78), Valencia (57,20 SD 7,18), Andalucia (57,67 SD 6,04) and Murcia(57,19 SD 5,50). By competential component, the best result corresponded to the area of communication (80.11% of ideal) and the worse one to family attention (45,54%). By areas of knowledge was detected, the greater in abdominal pain (75,94 SD 14,70) and the minor in diabetes (43,36 SD 15.97). The global coefficient of reliability of the test was 0,79. Conclusions: This study shows to the competential map of the Spanish general practitioner and the existing differences between Communities. The clinical competence is globally good. This type of study contributes to an integral vision of the general practitioner on its CPD, it will serve to him as a guide in their formation, to obtain the professional excellence and to maintain it (AU)