Building Strong Primary Healthcare Systems in Greece.

The healthcare system in Greece has undergone significant changes over the past 10 years. While there have been some positive developments, such as improvements in primary care and public health, there are still many challenges that need to be addressed. One of the major changes in the Greek healthcare system over the past decade has been the impact of the country's economic crisis. The government has had to implement a series of austerity measures, including significant cuts to healthcare funding. This has had a negative impact on the availability and quality of care, particularly for those on low incomes or living in rural areas.

Can Sulfonylureas for Agricultural Use Cause Diabetes? A Report of Three Cases.

Sulfonylureas (SUs) are commonly used as herbicides. Many farmers and other professionals use SUs for cereal, strawberry, and grape crops. This study examines the possible association between exposure to SUs herbicides and the risk of developing type 2 diabetes (T2D). The study presents three cases of unrelated agronomists who had used SUs for more than three decades and developed T2D. The objective was to investigate the association between occupational dermal and inhalation exposure to herbicides and T2D. Further studies with a larger sample size are needed to determine the association and to help develop prevention strategies.

The Rural Family Medicine Café Project: A Social Media Strategy to Reduce Occupational Isolation and Improve Support for Rural Healthcare Professionals.

Background: Globally rural medicine is currently suffering from staff shortages. Social and professional isolation are identified as significant pressures on health professionals working in rural areas. Social media (SOME) has created new methods of social engagement where conventional forms have failed. The Rural Family Medicine Café (RFMC) is a SOME project created to engage and support those interested in rural family medicine thus decreasing occupational isolation. Methods: A quantitative analysis of SOME activity associated with the RFMC was done by measuring the frequency of #ruralcafe, #ruralwomenGP, #ruralGP, #ruralstories, and #ruralmedicine from October 2015 to October 2016 along with the number of Facebook page likes and YouTube views. A time series and regression analysis were done to assess the correlation between the frequencies of hashtag use and the number of new likes or views. A qualitative analysis of the content of tweets using the associated hashtags and comments on the RFMC YouTube videos was then done to assess participants' response to the RFMC. To add context to the data collected, regularly attending participants were invited for a semi-structured interview. Results: There was a positive trend in the number of Facebook page likes (+273%) and Twitter hashtag use (+2,458%) but a negative trend (-92%) in the number of RFMC YouTube views. There was no statistically significant relationship between the number of views on the RFMC YouTube and RFMC associated SOME activity (p = 0.141). A significant relationship was shown between the number of Facebook page likes and the number of views on the RFMC YouTube (p = 0.037). Participants felt positively about the RFMC with recurring themes of; promotion, advocacy, public health, engagement, inspire, sharing, spreading information, feeling connected and general positive comments such as "enjoying tweets," "great discussion." Participants shared anecdotes, useful links, and book recommendations. Conclusion: The RFMC has seen an increase in the amount of associated SOME activity despite having less viewers. This is most likely due to the few participants of the RFMC continuing the café discussions on SOME, particularly Twitter, and engaging outside of the RFMC. The RFMC has developed into a virtual community which is reducing occupational isolation for its participants.

Adherence to inhalers and comorbidities in COPD patients. A cross-sectional primary care study from Greece.

BACKGROUND: Comorbidities and adherence to inhaled therapy appears to have a major impact on treatment goals, health status and disease control in chronic obstructive pulmonary disease (COPD). Aim of the study was to assess levels of adherence to inhalers, comorbidities and associations with COPD outcomes in patients residing in rural and semi-urban areas of Greece. METHODS: Two hundred fifty-seven COPD patients were enrolled from primary health care in 2015-2016. Physicians used structured interviews and questionnaires to assess quality of life and disease status. Patients were classified into groups according to GOLD 2019 guidelines (based on CAT and mMRC). Adherence to inhalers was measured with the Test of Adherence to Inhalers (TAI). Multivariate linear and logistics regression models were used to assess associations between comorbidities and adherence to inhalers with COPD outcomes, including CAT and mMRC scores, exacerbations and GOLD A-D status. RESULTS: 74.1% of COPD patients reported poor adherence, while most of them were characterized as deliberate non-compliers (69.5%). 77.1% had ≥2 comorbidities, with overweight/obese (82.2%), hypertension (72.9%) and diabetes mellitus (58%) being the most prevalent. In multivariate analysis, COPD outcomes having significant associations with poor adherence included worse health status [OR (95% CI) 4.86 (1.61-14.69) and 2.93 (1.51-5.71) based on CAT and mMRC, respectively], having ≥2 exacerbations in the past year [4.68 (1.51-4.44)], and disease status e.g., be in groups C or D [3.13 (1.49-8.53) and 3.35 (1.24-9.09) based on CAT and mMRC, respectively). Subjects with gastroesophageal reflux showed better inhaler adherence [OR (95% CI) 0.17 (0.6-0.45)], but none of the comorbid conditions was associated with COPD outcomes after adjustments. CONCLUSIONS: Poor adherence to inhalers and comorbidities are both prevalent in COPD patients of primary care residing in rural/semi-urban areas of Greece, with adherence influencing COPD outcomes. Raising awareness of patients and physicians on the importance of comorbidities control and inhaler adherence may lead to interventions and improve outcomes.

Associations of sense of coherence and self-efficacy with health status and disease severity in COPD.

Sense of coherence and self-efficacy has been found to affect health-related quality of life in chronic diseases. However, research on respiratory diseases is limited. Here we report findings on quality of life (QoL) of COPD patients and the associations with coherence and self-efficacy. This study consists of the Greek national branch of the UNLOCK study, with a sample of 257 COPD patients. Coherence and self-efficacy are positively inter-correlated (Pearson rho = 0.590, p < 0.001). They are negatively correlated with the quality of life (CAT) [Pearson rho: coherence = -0.29, p < 0.001; self-efficacy = -0.29, p < 0.001) and mMRC (coherence = -0.37, p < 0.001; self-efficacy rho = -0.32, p < 0.001)]. Coherence is inversely associated with (Global Initiative for Chronic Obstructive Lung Disease) GOLD 2018-CAT and GOLD 2018-mMRC classification and "having at least one exacerbation in the past year". Findings are stressing the need for their incorporation in primary health care and COPD guidance as it maybe that enhancing coherence and self-efficacy will improve QoL.

Subjective sleep quality is associated with disease status in COPD patients. The cross-sectional Greek UNLOCK study.

PURPOSE: The association of chronic obstructive pulmonary disease (COPD) severity and related health status with sleep quality remains unclear. We aimed to investigate the association between COPD and sleep quality in the Greek national branch of the UNLOCK cohort. METHODS: A sample of 257 COPD patients enrolled cross-sectionally from primary care in Greece. Sleep quality was assessed by the COPD and Asthma Sleep Impact Scale (CASIS-7 items) questionnaire (higher score indicates worse sleep quality). We tested for associations of sleep impairment with health status (CAT and mMRC scores), exacerbations, hospitalizations, GOLD 2018 ABCD status, inhaler adherence, frailty, and sense of coherence, adjusting for age, gender, smoking status, and comorbidities. RESULTS: The majority of patients reported uncontrolled symptoms (91% with ≥ 10 CAT or 61% with ≥ 2 mMRC). Mean (SD) age was 65 (12.3) with 79% males. CASIS-7 mean (SD) score was 37.7 (12.9). After adjustments, CASIS was significantly associated with worse health status (e.g., CASIS increased with CAT ≥ 10 [ß = 12.53, (95% CI, 6.82, 18.25); p < 0.001], mMRC ≥ 2 [ß = 4.96, (95% CI, 1.56, 8.34); p = 0.004]), COPD severity (CAT-based GOLD BD [ß = 8.88 (95% CI, 2.50, 15.26); p = 0.007]), frailty [ß = 8.85 (95% CI 4.45,13.25); p < 0.001], and sense of coherence [ß = -0.14 (95% CI -0.21, -0.06), p < 001]. When using a CASIS cut-off score of 30 as indicator of sleep impairment, additional to the aforementioned associations, we found increased risk for sleep impairment with ≥ 2 exacerbations/year and poor inhaler adherence (p value < 0.05). CONCLUSIONS: Our study suggests that worse health status and COPD severity are associated with poor sleep quality in COPD patients.

Assessing spirituality: is there a beneficial role in the management of COPD?

Here,we report on the role of spirituality assessment in the management of chronic obstructive pulmonary disease (COPD). Although a positive effect of addressing spirituality in health care has been proved in a number of chronic diseases, its potential in COPD has received less attention. Although limited, available evidence suggests that spirituality may play an important role in improving quality of life of patients with COPD. The fruitful results in other long-term conditions may lay the foundation for further research on addressing spirituality in COPD. This should focus where the burden of COPD is greatest, including low-resource settings globally. Implementation research should include exploration of an acceptable consultation process to identify patients who would welcome spiritual discussions; how to integrate spiritual approaches into health care professional curricula so that they are aware of its importance and have the confidence to raise it with patients and how to integrate spiritual approaches into holistic COPD care.

COPD patients' characteristics, usual care, and adherence to guidelines: the Greek UNLOCK study.

PURPOSE: GOLD guidelines classify COPD patients into A-D groups based on health status as assessed by COPD Assessment Test (CAT) or mMRC tools and exacerbations and recommend single or dual long-acting bronchodilators as maintenance therapy, with additional inhaled corticosteroids (ICS) if the disease remains uncontrolled. We aimed to classify primary care COPD patients into A-D groups, assess usual treatment and adherence to guidelines, potential mismatches between CAT-and mMRC-based classification and described symptoms within groups. PATIENTS AND METHODS: A total of 257 primary care COPD patients were enrolled between 2015 and 2016 in Greece. Physicians used structured interviews to collect cross-sectional data including demographics, symptoms, CAT, mMRC scores, and medications. Patients were classified into A-D groups based on CAT and mMRC, and prevalence of symptoms and medication was estimated within A-D groups. Interviews with physicians were also performed to explore additional issues about treatment and adherence to guidelines. RESULTS: Mean (SD) age was 65 (12.3) years with 79% males. The majority of patients reported uncontrolled symptoms (91% and 61% with ≥10 CAT or ≥2 mMRC scores, respectively). Thirty-seven percentage had $2 exacerbations in the past year. Group B was the largest followed by Groups D, A, and C. Patients were classified as more severe by CAT than by mMRC. In all groups, the majority were treated with combined long-acting beta agonist/ICS (> 50%). When patients were asked to report their main symptoms, dyspnea and cough were the most important symptoms mentioned, and there was a great variation between the A-D groups. However, Groups A-C reported mainly morning symptoms, whereas Group D suffered symptoms all day. Physicians reported a significant number of barriers to implementing guidelines, eg, frequent lack of guideline updates, access to diagnostic procedures, and prescription-reimbursement issues. CONCLUSION: Our study confirms poor adherence to guidelines regarding treatment with an overuse of ICS and important barriers to implementation. A mismatch in classification occurs depending on the tool used, which can mislead clinicians in their choice of treatment.

Determinants of frailty in primary care patients with COPD: the Greek UNLOCK study.

BACKGROUND: Frailty is a state of increased vulnerability that has a significant risk of unfavorable outcomes such as increased dependency and/or death, but little is known about frailty in people with chronic obstructive pulmonary disease (COPD). METHOD: We aimed to determine the prevalence of frailty in COPD patients and to identify the associated risk factors. Two hundred fifty-seven COPD patients enrolled from primary care in Greece between 2015 and 2016. Physicians used structured interviews to collect cross-sectional data including demographics, medical history, symptoms and COPD Assessment Tool (CAT) or modified Medical Research Council Dyspnea scale (mMRC) score. Patients were classified into severity groups according to GOLD 2017 guidelines. Participants completed the The Frail Non-Disabled (FiND) questionnaire, exploring the frailty and disability domains. In the present analyses, frail patients with and without mobility disability were pooled and were compared to non-frail patients. Factors associated with frailty were analyzed using univariate and multivariate logistic regression. RESULTS: Mean (SD) age was 65 (12.3) with 79% males. The majority of patients suffered with frailty (82%) of which 76.8% had mobility disability. 84.2% were married/with partner and 55.4% retired. 55.6% were current smokers. Uncontrolled disease (≥10 CAT score) was reported in 91.1% and 37.2% of patients had ≥2 exacerbations in the past year. Dyspnea (38%) and cough (53.4%) were the main symptoms. Main comorbidities were hypertension (72.9%), hyperlipidaemia (24.6%) and diabetes (11%). Risk of frailty was significantly increased with age (OR; 95%CI: 1.05; 1.02-1.08), hypertension (2.25; 1.14-4.45), uncontrolled disease (≥10 CAT score 4.65; 1.86-11.63, ≥2 mMRC score 5.75 (2.79-11.85) or ≥ 2 exacerbations 1.73; 1.07-2.78), smoking cessation (ex compared to current smokers: 2.37; 1.10-5.28) and GOLD status (B&D compared to A&C groups: CAT-based 4.65; 1.86-11.63; mMRC-based: 5.75; 2.79-11.85). In multivariate regression smoking cessation and GOLD status remained significant. Gender, body mass index, occupational or marital status, symptoms and other comorbidities were not significant. CONCLUSIONS: Frailty with mobility disability is common in COPD patients and severity of disease increases the risk. It is possible that frail patients are more likely to quit smoking perhaps because of their disability and uncontolled disease. Routine assessment of frailty in addition to COPD control may allow early interventions for preventing or delaying progression of frailty and improvement in COPD disease.