Karlos Naberan

Attitudes Toward the Diagnosis of Chronic Obstructive Pulmonary Disease in Primary Care

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.

Utilización de la espirometría en el diagnóstico y tratamiento de la EPOC en atención primaria

Objetivo El objetivo del estudio ha sido evaluar las deficiencies y necesidades para la correcta utilizacion de la espirometria en el diagnostico y seguimiento del paciente con enfermedad pulmonar obstructiva cronica (EPOC) en atencion primaria (AP) y conocer las pautas habituales de tratamiento de esta enfermedad. Metodos Participaron 839 medicos de AP y cada uno de ellos cumplimento 2 cuestionarios, uno sobre el tratamiento de la EPOC y otro de utilizacion de la espirometria en su diagnostico y seguimiento. Resultados Destaco el bajo indice tanto de respuestas a la pregunta sobre la clasificacion de los pacientes en funcion de la gravedad de la obstruccion (no respondio el 10,7%) como de respuestas correctas en las preguntas sobre el tratamiento broncodilatador en fase estable (respuestas correctas: 15,1%). Las mayores tasas de respuestas correctas se obtuvieron en las preguntas referentes a la indicacion de la espirometria, todas ellas con un indice de acierto superior al 60%. Solo un 59,2% de los centros de AP realizaban espirometrias, sobre todo debido a la falta de formacion. En mas de un 30% de los casos el personal de enfermeria no habia recibido formacion especifica, lo que se reflejaba en un escaso seguimiento de las normativas en cuanto a calibracion (un 10,9% de los centros la realizaba diariamente), limpieza de los aparatos (un 13,9% no la hacia nunca) y recomendaciones al paciente (un 30% no daba recomendaciones el dia antes). Conclusiones Los medicos de AP conocen la utilidad de la espirometria en el diagnostico y seguimiento de la EPOC. Identifican la presencia de una obstruccion al flujo aereo, pero no se clasifica correctamente a los pacientes en funcion de su gravedad. Se ha observado una escasa disponibilidad de la espirometria en los centros de AP, asi como una escasa formacion en su manejo, lo que se refleja en un escaso seguimiento de las normativas de realizacion de la prueba.

Problemas con el diagnóstico de la EPOC en atención primaria

Objetivo La prevalencia de la enfermedad pulmonary obstructiva cronica (EPOC) ha aumentado en el sexo femenino, pero aun se considera una enfermedad que afecta sobre todo a los varones. Este estudio pretendio identificar las actitudes diagnosticas de los medicos de atencion primaria frente a pacientes con EPOC segun su sexo y los resultados de la espirometria. Metodo Participo en el estudio una muestra representativa de 839 medicos de atencion primaria. Cada uno de ellos resolvio uno entre 8 casos posibles de pacientes con EPOC. La mitad de estos correspondia a un paciente varon y la otra mitad a una mujer con historia clinica y exploracion fisica identicas. Tras la historia y la exploracion fisica se solicito a los participantes un diagnostico provisional, asi como las pruebas diagnosticas necesarias. Se facilitaron despues los resultados de la espirometria que mostraban una obstruccion de caracter moderado o grave. Los resultados negativos de una prueba broncodilatadora y de una prueba con corticoides orales se dieron a continuacion. Resultados La EPOC fue un diagnostico provisional mas 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 desaparecia despues de mostrar los resultados anormales de la espirometria. Los pacientes con una obstruccion de caracter grave eran diagnosticados con mayor probabilidad de EPOC que aquellos con una obstruccion moderada OR: 1,5; IC del 95%, 1,08-2,09). Conclusiones Existe un sesgo diagnostico en funcion del sexo del paciente. En muchas ocasiones no se diagnostica a los pacientes con EPOC que presentan una obstruccion moderada. Estos sesgos podrian comprometer el diagnostico precoz de la EPOC en un grupo cada vez mas frecuente de individuos en riesgo.

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.

Factors determining the quality of life of patients with COPD in primary care

Objectives: To describe the health-related quality of life (HRQL) in a cohort of COPD patients recruited in primary care and identify the variables of the patients and the treatment associated with impaired HRQL. Method: Multicenter, observational study of patients with COPD recruited in Primary Care centers. Data regarding HRQL measured by the St. Georges respiratory questionnaire (SGRQ) are presented. The total population was divided into two subgroups, high and Low SGRQ, using the median of the total SGRQ score. Univariate analysis and logistic regression analysis with calculation of adjusted odds ratios were used to investigate the factors significantly associated with a higher SGRQ score (poor HRQL). Results: A total of 27 investigators included 222 valid patients with a mean age of 68.2 years (SD = 9.9) and a mean FEV1(%) of 49.2% (SD = 15.4%). The median total SGRQ score was 39.5 and patients with a high score had a longer evolution of COPD (p < 0.0001), more severe dyspnea (p < 0.0001) and a worse FEV1(%) (46.3% vs. 51.9%; p = 0.008). Factors independently associated with the total SGRQ score were cough and dyspnea, duration of COPD and treatment with inhaled steroids. Conclusion: Patients with COPD controlled in primary care demonstrate an important impairment in HRQL, with chronic cough and dyspnea being associated with more impaired HRQL. Strategies aimed at modifying these factors should significantly improve the well-being of COPD patients.

Socioeconomic status and health-related quality of life of patients with chronic obstructive pulmonary disease.

Background: Socioeconomic status (SES) is an important determinant of health and premature death. However, the impact of poor SES on the health status of patients with chronic obstructive pulmonary disease (COPD) has not been well determined. Objective: It was our aim to assess the impact of SES on the quality of life in COPD patients. Methods: This was a cross-sectional, observational, multicenter study. A total of 4,574 patients completed the EuroQol 5-dimension questionnaire (EQ-5D) and the Airways Questionnaire 20 (AQ20). SES was based on the subject’s occupation and educational level. Occupational categories were based on the major group classification of the International Standard Classification of Occupations. Results: The mean age of the population was 67.1 years and the mean forced expiratory volume was 43.4%. There was a gradient of impairment in health-related quality of life (HRQoL) according to the educational level, with significantly worse scores for the EQ-5D and the AQ20 for medium and low educational levels compared with high education (p < 0.001). Similarly, HRQoL was also significantly impaired in more unskilled workers, with a gradient of the AQ20 from 8.6 units (SD 4.8) in class I to 10.1 units (4.6) in class V (p < 0.001) and from 0.75 units in class I to 0.63 units in class V for the EQ-5D index, as well as from 62.9 units in class I to 55.6 units in class V for the EQ-5D visual analogue scale (p < 0.001 for all comparisons). These differences remained significant after controlling for covariates. Conclusions: Patients with a lower educational level and belonging to the unskilled professional groups had a poorer HRQoL. This is evident even in a country where access to health care services is universal and free.

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.

Use of Spirometry in the Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease in Primary Care

OBJECTIVE The aim of this study was to assess the use of spirometry for the diagnosis and follow-up of patients with chronic obstructive pulmonary disease (COPD) in primary care in terms of deficiencies and the requirements for its correct use, and to identify the regimens most commonly used in patients with COPD. METHODS The study included 839 primary care physicians, each of whom completed 2 questionnaires, one on treatment of COPD and the other on the use of spirometry for diagnosis and follow-up of the disease. RESULTS Notable among the results was the high number of questionnaires in which no response was given to the question on classification of patients according to the severity of airway obstruction (10.7% of cases) and the low number of correct responses to questions on treatment with bronchodilators during the stable phase of COPD (15.1%). The highest rate of correct responses was for questions regarding the indication for spirometry, all of which were answered correctly in more than 60% of cases. Only 59.2% of primary health care centers performed spirometry, mainly due to a lack of training. In more than 30% of cases the nursing staff had not received specific training, a finding that was reflected in the poor compliance with guidelines for calibration (10.9% of health care centers performed daily calibrations), cleaning of the spirometer (in 13.9% of cases the equipment was never cleaned), and providing patients with pretest recommendations (30% did not provide recommendations the day before spirometry). CONCLUSIONS Primary care physicians are aware of the usefulness of spirometry for the diagnosis and follow-up of COPD. Although they are able to recognize airflow obstruction, they do not classify patients correctly in terms of severity. Very limited availability of spirometry was observed in primary health care centers and there was little training in the use of the technique, a finding reflected in the poor compliance with guidelines for its use.

Effect of Various Antimicrobial Regimens on the Clinical Course of Exacerbations of Chronic Bronchitis and Chronic Obstructive Pulmonary Disease in Primary Care

AbstractAim: To assess whether the empirical administration of different antibiotics for exacerbations of chronic bronchitis and chronic obstructive pulmonary disease (COPD) in the primary-care setting is associated with a different clinical course, principally related to the speed of onset of action. Design and setting: Observational, non-randomised, open-label study carried out between February 2001 and May 2002 in 252 primary-care practices in Spain. Participants: The study included patients diagnosed with an exacerbation of chronic bronchitis or COPD. Information was requested on the first ten patients attending each clinic with a diagnosis of exacerbation of their chronic bronchitis or COPD within the study dates. All patients were followed up for 30 days, with an intermediate visit at 10 days at which they were asked about the duration of the symptoms; the presence of symptoms was assessed at 3, 5 and 10 days. Three antibiotic regimens were evaluated: amoxicillin 500mg plus clavulanic acid 125mg (co-amoxiclav) three times daily for 10 days, clarithromycin 500mg twice daily for 10 days, and moxifloxacin 400mg once daily for 5 days. Results: 252 general practitioners participated in the study, registering 1456 patients who met inclusion criteria. The clinical cure rate, defined as the remission of the three cardinal symptoms of exacerbation (increased expectoration, change in sputum purulence, and increased dyspnoea) were similar on the tenth day: 67% in the group receiving moxifloxacin, 65% in those taking co-amoxiclav, and 64% in those taking clarithromycin (p = 0.38). However, differences in the clinical cure rates were observed on day 3 (moxifloxacin 20%, co-amoxiclav 9.6%, and clarithromycin 6.5%) and day 5 (moxifloxacin 49%, co-amoxiclav 26.5% and clarithromycin 30%). The cure rates were significantly higher in the moxifloxacin group than in either of the other two treatment groups (p < 0.001 for both days). Conclusions: The aim of antimicrobial therapy should be to reduce both the rate of therapeutic failure and the duration of symptoms. Even though the clinical cure rates in this study were similar at 10 days, the time to resolution of symptoms was shorter in the patients in the moxifloxacin group than in the other two groups.

Utilización de Internet en un estudio multicéntrico sobre EPOC en atención primaria. Fase piloto del estudio EFEMAP

Objetivos Conocer la viabilidad de la recogida y transmision de datos clinicos por Internet en un estudio multicen-trico en atencion primaria Pacientes Y Metodos Estudio observacional, multicentrico sobre una poblacion de pacientes con enfermedad pul-monar obstructiva cronica agudizada. Todos los datos se recogieron en un formulario electronico disenado especificamente, que se encontraba incorporado en un ordenador portatil de bolsillo. La transmision de los datos se efectuo on line a una base de datos unificada mediante conexion telefonica por modem Resultados Participaron en esta fase piloto 39 investigadores, que incluyeron a 324 pacientes durante 3 meses. Se generaron 37 consultas telefonicas, la mayoria (54%) referida al funcionamiento del cuestionario electronico, que se soluciono en un promedio de 5,44 min. La metodologia utilizada no presento ningun problema tecnico de importancia ni se detecto ninguna perdida de informacion Conclusiones La utilizacion de Internet en estudios multicentricos en atencion 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 gra-bacion de los mismos tras finalizar el estudio