Exacerbations worsen the quality of life of chronic obstructive pulmonary disease patients in primary healthcare.

AIMS: To investigate the evolution of the quality of life of patients with chronic obstructive pulmonary disease (COPD) and quantify the impact of exacerbations on the deterioration of quality of life over 2 years. METHODS: Multicentre, observational, prospective 2-year study carried out in primary care. Patients with COPD were seen every 6 months. All the exacerbations developing during the study period were recorded and the quality of life of these patients was measured with the St. George's Respiratory Questionnaire (SGRQ). RESULTS: Twenty-seven physicians participated and collected information on 136 patients with a mean age of 70 years (SD: 9.7) and a mean forced expiratory volume in 1 s (FEV(1)) of 48.7% predicted (SD: 14.5%). The mean global score of the SGRQ was 39.6 at the beginning of the study and 37.9 at the end. Patients without exacerbations improved an average of -5.32 units compared with a worsening of +0.2 among patients with exacerbations (p = 0.023). Among the latter, patients with only one exacerbation improved -3.8 units (p = 0.012) compared with a worsening of +2.4 in those with two or more exacerbations (p = 0.134). The impact of exacerbations was greater in patients with more preserved pulmonary function, with a change in the SGRQ among patients with or without exacerbations of +0.23 and -6.17 (p = 0.017), respectively in patients with a FEV(1) > 50%, vs. +0.18 and -4.39 (p = 0.32) in patients with a FEV(1)

Discrepancy between antibiotics administered in acute exacerbations of chronic bronchitis and susceptibility of isolated pathogens in respiratory samples: multicentre study in the primary care setting.

A national multicentre prevalence study was undertaken to determine the bacterial strains associated with mild-to-moderate acute exacerbations of chronic bronchitis (AECB) in the primary care setting and the susceptibility of isolated pathogens to different antimicrobials usually prescribed to these patients. All samples were processed by a central reference laboratory. Microdilution tests were carried out to establish the minimum inhibitory concentration (MIC) of various antimicrobials. A double-disk test was performed to establish the macrolide resistance phenotype in Streptococcus pneumoniae. Tests to detect the presence of beta-lactamase in Haemophilus influenzae and Moraxella catarrhalis and polymerase chain reaction to detect the presence of ermB and mefA genes in S. pneumoniae isolates were also performed. A total of 1537 patients were included in the trial and 468 microorganisms were isolated from sputum samples, with the most frequent isolates being S. pneumoniae (34.8%), M. catarrhalis (23.9%) and H. influenzae (12.6%). Resistance rates of pneumococci were 47.2% for penicillin, 1.2% for amoxicillin, 34.3% for macrolides (87.5% of which showed high-level resistance), 13.6% for cefuroxime/axetil and 4.2% for levofloxacin. No bacterial isolates showed resistance to telithromycin. Empirical antibiotic treatment was prescribed to 98.3% of patients, including macrolides to 36.6%, amoxicillin with or without clavulanic acid to 32.3% and fluoroquinolones to 16.1%. In conclusion, S. pneumoniae was the most frequently isolated bacteria in patients with mild-to-moderate AECB. Despite the high rates of resistance of pneumococci to macrolides, they continue to be the most widely used antibiotics in primary care to treat AECB.

[Risk factors for increased cost of exacerbations of chronic bronchitis and chronic obstructive pulmonary disease]. / Factores de riesgo de elevado coste de las agudizaciones de la bronquitis crónica y la EPOC.

OBJECTIVE: To identify what variables characterizing the patients, exacerbations, and treatment of chronic bronchitis and chronic obstructive pulmonary disease (COPD) are associated with a higher direct health cost. METHOD: Observational pharmacoeconomic study of exacerbations of chronic bronchitis and COPD (of probable bacterial etiology, defined as Anthonisen types I or II). Direct health costs were assessed during 30 days of follow-up. Logistic regression was employed for statistical analysis, with calculation of the adjusted odds ratios (OR). An exacerbation cost greater than 150 euros was defined as the dependent variable. RESULTS: Data on 1164 patients were collected by 252 physicians. Pharmacoeconomic data were complete in 947 patients (82.6%). In the first 30 days, 206 sought medical attention because of unsatisfactory response to treatment (21.8%), 69 (7.3%) attended the emergency room, and 22 (2.3%) were admitted to hospital. Overall, 101 exacerbations (10.7%) were classified as high cost (> 150 euros). Continuous oxygen therapy (OR = 7.58) and previous hospitalization (OR = 2.6) were associated with high-cost exacerbations, whereas diagnosis of chronic bronchitis (OR = 0.41) and treatment of the exacerbation with moxifloxacin or amoxicillin-clavulanic acid as opposed to clarithromycin (OR = 0.38) were associated with low-cost exacerbations. CONCLUSION: Treatment failure was reported for 21.8% of the patients with exacerbations of chronic bronchitis and COPD. Repeated medical visits and requests for complementary tests were the main factors responsible for increased cost. Variables associated with high-cost exacerbations were continuous oxygen therapy, previous hospitalization, and treatment with clarithromycin as opposed to moxifloxacin or amoxicillin-clavulanic acid.

Factores de riesgo de elevado coste de las agudizaciones de la bronquitis crónica y la EPOC / Risk factors for increased cost of exacerbations of chronic bronchitis and Chronic Obstructive Pulmonary Disease

Objetivo: Identificar las variables de los pacientes, de las agudizaciones y del tratamiento de la bronquitis crónica (BC) y la enfermedad pulmonar obstructiva crónica (EPOC) que se asocian con un mayor coste sanitario directo. Método: Estudio observacional y farmacoeconómico en pacientes con BC y EPOC con agudización de probable etiología bacteriana, definida por presentar 2 o más de los criterios de Anthonisen. Se siguió a los pacientes durante 30 días y se evaluaron los costes directos derivados de su atención. El análisis estadístico se efectuó mediante regresión logística con cálculo de las odds ratio (OR) ajustadas, considerando variable dependiente un coste de agudización superior a los 150 €. Resultados: Participaron 252 médicos que recabaron información sobre 1.164 pacientes. Se recogieron todos los parámetros farmacoeconómicos en 947 pacientes (82,6%). En los primeros 30 días, 206 acudieron por mala evolución (21,8%), 69 (7,3%) requirieron atención en urgencias y 22 (2,3%) precisaron ingreso. Se clasificaron como de coste elevado (> 150 €) 101 agudizaciones (10,7%). Las variables que se asociaron a un coste elevado fueron la oxigenoterapia continua (OR = 7,58) y la hospitalización previa (OR = 2,6), mientras que el diagnóstico de BC (OR = 0,41) y el tratamiento de la agudización con moxifloxacino o amoxicilina-ácido clavulánico, comparado con claritromicina (OR = 0,38), se asociaron a un coste bajo. Conclusión: Un 21,8% de los pacientes con agudización de la BC y EPOC fracasa, con lo que se genera un coste mayor, fundamentalmente por nuevas visitas médicas y solicitud de pruebas complementarias. Las variables que se asocian a una agudización de coste elevado son la oxigenoterapia continua, la hospitalización previa y el tratamiento con claritromicina comparada con moxifloxacino o amoxicilina-ácido clavulánico

Objective: To identify what variables characterizing the patients, exacerbations, and treatment of chronic bronchitis and chronic obstructive pulmonary disease (COPD) are associated with a higher direct health cost. Method: Observational pharmacoeconomic study of exacerbations of chronic bronchitis and COPD (of probable bacterial etiology, defined as Anthonisen types I or II). Direct health costs were assessed during 30 days of follow-up. Logistic regression was employed for statistical analysis, with calculation of the adjusted odds ratios (OR). An exacerbation cost greater than €150 was defined as the dependent variable. Results: Data on 1164 patients were collected by 252 physicians. Pharmacoeconomic data were complete in 947 patients (82.6%). In the first 30 days, 206 sought medical attention because of unsatisfactory response to treatment (21.8%), 69 (7.3%) attended the emergency room, and 22 (2.3%) were admitted to hospital. Overall, 101 exacerbations (10.7%) were classified as high cost (> €150). Continuous oxygen therapy (OR=7.58) and previous hospitalization (OR=2.6) were associated with high-cost exacerbations, whereas diagnosis of chronic bronchitis (OR=0.41) and treatment of the exacerbation with moxifloxacin or amoxicillin­clavulanic acid as opposed to clarithromycin (OR=0.38) were associated with low-cost exacerbations. Conclusion: Treatment failure was reported for 21.8% of the patients with exacerbations of chronic bronchitis and COPD. Repeated medical visits and requests for complementary tests were the main factors responsible for increased cost. Variables associated with high-cost exacerbations were continuous oxygen therapy, previous hospitalization, and treatment with clarithromycin as opposed to moxifloxacin or amoxicillin- clavulanic acid

[Attitudes toward the diagnosis of chronic obstructive pulmonary disease in primary care]. / Problemas con el diagnóstico de la EPOC en atención primaria.

OBJECTIVE: Although the prevalence of chronic obstructive pulmonary disease (COPD) has increased among women, it is still considered a disease that mainly affects men. This study aimed to identify the diagnostic attitudes of primary care physicians toward patients with COPD according to gender and spirometric results. METHODS: A representative sample of 839 primary care physicians participated in the study. Each physician dealt with 1 of 8 hypothetical cases based on a patient diagnosed with COPD. In half the cases, the physician was told the patient was a man. The other half of the physicians were told the same patient was a woman. After presentation of the medical history and results of physical examination, the physicians were asked to state a probable diagnosis and indicate the diagnostic tests that were necessary. They were then told the results of spirometry, which indicated obstruction ranging from moderate to severe. Negative results of bronchodilator tests and oral corticosteroid tests were then communicated. RESULTS: COPD was more likely to be the preliminary diagnosis for male patients than for females (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.15-2.1). This gender bias disappeared once the physicians were shown the abnormal results of spirometry. Patients with severe obstruction were more likely to be diagnosed with COPD than those with moderate obstruction (OR, 1.5; 95% CI, 1.08-2.09). CONCLUSIONS: There is gender bias in the diagnosis of COPD. Patients with moderate obstruction are often believed not to have COPD. These biases may compromise the early diagnosis of the disease in a group of patients with ever increasing risk.

Problemas con el diagnóstico de la EPOC en atención primaria / Attitudes toward the diagnosis of Chronic Obstructive Pulmonary Disease in primary care

Objetivo: La prevalencia de la enfermedad pulmonar obstructiva crónica (EPOC) ha aumentado en el sexo femenino, pero aún se considera una enfermedad que afecta sobre todo a los varones. Este estudio pretendió identificar las actitudes diagnósticas de los médicos de atención primaria frente a pacientes con EPOC según su sexo y los resultados de la espirometría. Método: Participó en el estudio una muestra representativa de 839 médicos de atención primaria. Cada uno de ellos resolvió uno entre 8 casos posibles de pacientes con EPOC. La mitad de éstos correspondía a un paciente varón y la otra mitad a una mujer con historia clínica y exploración física idénticas. Tras la historia y la exploración física se solicitó a los participantes un diagnóstico provisional, así como las pruebas diagnósticas necesarias. Se facilitaron después los resultados de la espirometría que mostraban una obstrucción de carácter moderado o grave. Los resultados negativos de una prueba broncodilatadora y de una prueba con corticoides orales se dieron a continuación. Resultados: La EPOC fue un diagnóstico provisional más probable para los pacientes varones que para las mujeres (odds ratio [OR]: 1,55; intervalo de confianza [IC] del 95%, 1,15-2,1). Este sesgo desaparecía después de mostrar los resultados anormales de la espirometría. Los pacientes con una obstrucción de carácter grave eran diagnosticados con mayor probabilidad de EPOC que aquellos con una obstrucción moderada OR: 1,5; IC del 95%, 1,08-2,09). Conclusiones: Existe un sesgo diagnóstico en función del sexo del paciente. En muchas ocasiones no se diagnostica a los pacientes con EPOC que presentan una obstrucción moderada. Estos sesgos podrían comprometer el diagnóstico precoz de la EPOC en un grupo cada vez más frecuente de individuos en riesgo

Objective: Although the prevalence of chronic obstructive pulmonary disease (COPD) has increased among women, it is still considered a disease that mainly affects men. This study aimed to identify the diagnostic attitudes of primary care physicians toward patients with COPD according to gender and spirometric results. Methods: A representative sample of 839 primary care physicians participated in the study. Each physician dealt with 1 of 8 hypothetical cases based on a patient diagnosed with COPD. In half the cases, the physician was told the patient was a man. The other half of the physicians were told the same patient was a woman. After presentation of the medical history and results of physical examination, the physicians were asked to state a probable diagnosis and indicate the diagnostic tests that were necessary. They were then told the results of spirometry, which indicated obstruction ranging from moderate to severe. Negative results of bronchodilator tests and oral corticosteroid tests were then communicated. Results: COPD was more likely to be the preliminary diagnosis for male patients than for females (odds ratio [OR], 1.55; 95% confidence interval [CI], 1.15-2.1). This gender bias disappeared once the physicians were shown the abnormal results of spirometry. Patients with severe obstruction were more likely to be diagnosed with COPD than those with moderate obstruction (OR, 1.5; 95% CI, 1.08-2.09). Conclusions: There is gender bias in the diagnosis of COPD. Patients with moderate obstruction are often believed not to have COPD. These biases may compromise the early diagnosis of the disease in a group of patients with ever increasing risk

Economic evaluation of the antibiotic treatment of exacerbations of chronic bronchitis and COPD in primary care.

This was an observational and economic survey performed in primary care practices throughout Spain to assess the effectiveness and direct medical costs derived from antibiotic treatment of exacerbations of chronic bronchitis (CB) and chronic obstructive pulmonary disease (COPD) in primary care. A total of 252 physicians included 1456 valid patients, 80% were male and the mean age was 68.2 years (SD = 9.8). The antibiotic treatment administered was moxifloxacin in 575 (39.5%), amoxicillin/clavulanate in 460 (31.6%) and clarithromycin in 421 (28.9%). No significant differences were found in clinical and demographic characteristics between treatment arms. The 30-days follow-up visit was completed by 1097 (75%) patients, who were therefore valid for economic evaluation. During follow-up, 440 new medical visits were generated, 69 patients required attendance in emergency wards (6.3%) and 22 were hospitalised (2%). The overall mean cost of exacerbation was Euro 118.58 [95% confidence interval (CI) = Euro 92.2-144.9] and Euro 52.44 (44.2%) were due to therapeutical failure. The mean cost of exacerbation was Euro 111.46 (95% CI = Euro 73.4-149.5) for patients treated with moxifloxacin, Euro 109.45 (95% CI = Euro 68.2-150.7) for those treated with amoxicillin/clavulanic acid and Euro 138.95 (95% CI = Euro 89.4-188.5) for patients receiving clarithromycin. In conclusion, a significant number of patients require new medical interventions after ambulatory treatment of exacerbations of CB or COPD. The mean cost of an exacerbation was Euro 118.58 and failure was responsible for 44.2% of the total cost of exacerbation.

[Use of the Internet in a multicenter study of chronic obstructive pulmonary disease in primary care. Pilot phase of the EFEMAP study]. / Utilización de Internet en un estudio multicéntrico sobre EPOC en atención primaria. Fase piloto del estudio EFEMAP.

OBJECTIVE: To determine the reliability of clinical data collection and transmission by Internet in a multicenter primary care study. PATIENTS AND METHODS: Multicenter, observational study of a population of patients with exacerbated chronic obstructive pulmonary disease (COPD). All data were gathered in a specifically designed digital program on a palm-held pocket computer. Information was transmitted on-line by modem to a central database. RESULTS: Thirty-nine researchers participated in this pilot phase. Over three months 324 patients were treated. Thirty-seven telephone consultations were generated, most (54%) in reference to how the digitized questionnaire worked. Questions were solved in a mean 5.44 minutes. No important technical problems occurred and no information was lost. CONCLUSIONS: The use of the Internet to transfer data for multicentric studies in primary care is possible. This system should be more widely used in the future, as it allows faster data collection and eliminates the need to input data at the end of the study.

Utilización de Internet en un estudio multicéntrico sobre EPOC en atención primaria. Fase piloto del estudio EFEMAP / Use of the Internet in a multicenter study of chronic obstructive pulmonary disease in primary care. Pilot phase of the EFEMAP study

OBJETIVOS: Conocer la viabilidad de la recogida y transmisión de datos clínicos por Internet en un estudio multicéntrico en atención primaria. PACIENTES Y MÉTODOS: Estudio observacional, multicéntrico sobre una población de pacientes con enfermedad pulmonar obstructiva crónica agudizada. Todos los datos se recogieron en un formulario electrónico diseñado específicamente, que se encontraba incorporado en un ordenador portátil de bolsillo. La transmisión de los datos se efectuó on line a una base de datos unificada mediante conexión telefónica por módem. RESULTADOS: Participaron en esta fase piloto 39 investigadores, que incluyeron a 324 pacientes durante 3 meses. Se generaron 37 consultas telefónicas, la mayoría (54 per cent) referida al funcionamiento del cuestionario electrónico, que se solucionó en un promedio de 5,44 min. La metodología utilizada no presentó ningún problema técnico de importancia ni se detectó ninguna pérdida de información. CONCLUSIONES: La utilización de Internet en estudios multicéntricos en atención primaria es posible. Este sistema debe extenderse en un futuro, pues permite una rapidez superior en la entrada de datos y elimina la necesidad de grabación de los mismos tras finalizar el estudio (AU)

Recomendaciones para la atención al paciente con enfermedad pulmonar obstructiva crónica / Guidelines for care of the patient with chronic obstructive pulmonary disease

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