Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.

https://www.who.int/respiratory/copd/GOLD_WR_06.pdf

Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary.

OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

Representatives from many countries serve as a network for the dissemination and implementation of programs for diagnosis, management, and prevention of COPD. The GOLD Board of Directors is grateful to the many GOLD National Leaders who participated in discussions of concepts that appear in GOLD reports.

Global initiative for chronic obstructive lung disease.

This new edition of Ann Bowling's well-known and highly respected text has been thoroughly revised and updated to reflect key methodological developments in health research. It is a comprehensive, easy to read, guide to the range of methods used to study and evaluate health and health services. It describes the concepts and methods used by the main disciplines involved in health research, including: demography, epidemiology, health economics, psychology and sociology.The research methods described cover the assessment of health needs, morbidity and mortality trends and rates, costing health services, sampling for survey research, cross-sectional and longitudinal survey design, experimental methods and techniques of group assignment, questionnaire design, interviewing techniques, coding and analysis of quantitative data, methods and analysis of qualitative observational studies, and types of unstructured interviewing. With new material on topics such as cluster randomization, utility analyses, patients' preferences, and perception of risk, the text is aimed at students and researchers of health and health services. It has also been designed for health professionals and policy makers who have responsibility for applying research findings in practice, and who need to know how to judge the value of that research.

Research Methods in Health. Investigating health and health services

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is characterised by both an accelerated decline in lung function and periods of acute deterioration in symptoms termed exacerbations. The aim of this study was to investigate whether these are related. METHODS: Over 4 years, peak expiratory flow (PEF) and symptoms were measured at home daily by 109 patients with COPD (81 men; median (IQR) age 68.1 (63-74) years; arterial oxygen tension (PaO(2)) 9.00 (8.3-9.5) kPa, forced expiratory volume in 1 second (FEV(1)) 1.00 (0.7-1.3) l, forced vital capacity (FVC) 2.51 (1.9-3.0) l); of these, 32 (29 men) recorded daily FEV(1). Exacerbations were identified from symptoms and the effect of frequent or infrequent exacerbations (> or < 2.92 per year) on lung function decline was examined using cross sectional, random effects models. RESULTS: The 109 patients experienced 757 exacerbations. Patients with frequent exacerbations had a significantly faster decline in FEV(1) and peak expiratory flow (PEF) of -40.1 ml/year (n=16) and -2.9 l/min/year (n=46) than infrequent exacerbators in whom FEV(1) changed by -32.1 ml/year (n=16) and PEF by -0.7 l/min/year (n=63). Frequent exacerbators also had a greater decline in FEV(1) if allowance was made for smoking status. Patients with frequent exacerbations were more often admitted to hospital with longer length of stay. Frequent exacerbations were a consistent feature within a patient, with their number positively correlated (between years 1 and 2, 2 and 3, 3 and 4). CONCLUSIONS: These results suggest that the frequency of exacerbations contributes to long term decline in lung function of patients with moderate to severe COPD.

https://thorax.bmj.com/content/thoraxjnl/57/10/847.full.pdf

Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease

Rationale: Despite substantial progresses on standard of care recommendations, management of Chronic Obstructive Pulmonary (COPD) patients show potential for improvement provided that patients’ heterogeneities are better understood. Objectives: To perform a population-based analysis of the COPD patients in Catalonia (ES) (7,5 M citizens) aiming at exploring the potential of the health registry information to enhance risk assessment and stratification in the clinical arena. Methods: The characteristics of 264,830 COPD cases registered in 2014 in the Health Surveillance System were assessed. Multiple logistic regression analysis was used to elaborate predictive models for four health indicators: (i) mortality, (ii) unplanned hospitalizations (all and COPD-related hospitalizations), (iii) multiple exacerbators, and, (iv) high users of healthcare resources. No clinical, nor forced spirometry data were available. Main Results: Multimorbidity, expressed by GMA (adjusted morbidity groups) scoring, was the covariate with highest impact in the four predictive models. This score explained a substantial percentage of interindividual variability (AUC): (i) mortality (0.763); (ii) unplanned hospitalizations (0.829); (iii) multiple exacerbators (0.766); and, (iv) higher use of healthcare resources (0.803). Patients above the 85 percentile in terms of healthcare costs per year represented 59% of the overall costs of COPD patients. Conclusions: The predictive models stress the explanatory role of the covariate multimorbidity. The results highly encourage further developments fostering interoperability between health registries and electronic health records to enhance clinical risk prediction.

Population-based analysis of COPD patients in Catalonia: implications for case management

The integration of health service provision is a conceptual framework that is easy to share from a theoretical point of view but raises problems when it comes to specifying actions and comparing the models and the results obtained. In general, the models for integration of services are hybrids and have been built up starting from an iterative process that receives the impact both of the general conditions (funding systems, health policies and social provisions) and of the local conditions (demography, types of supplier or available human resources). Until relatively recently high-tech hospitals were not aware of his dual function: A function of high-tech services to a very large part of the population but also a function of general hospital for the local community. Obviously, the strategy to address the problems of high technology can not be the same as to address the health problems of the community. Health professionals and organizations must adapt to provide the right services, avoiding the "one size fits all". In the workshop we will discuss the strengths and weaknesses of integrated care models in which it is involved high-tech hospital. It is therefore important to know the causes that drive transformation, levers for change and how to establish priorities.

/pdf/integrated-care-in-a-metropolitan-area-blurring-the-4r3q2yhju1.pdf

Joan Escarrabill

Papers

Population-based analysis of COPD patients in Catalonia: implications for case management

Integrated care in a metropolitan area: blurring the boundaries between high-tech hospital and the community

Health Case Support for Home Machanical Ventilation: Networking Versus Centralization

Do right what is right.

Estudio prospectivo de los enfermos que abandonan un servicio de urgencias antes de ser atendidos por el médico