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Aims: To identify the obstacles hindering the appropriate management of chronic obstructive pulmonary disease (COPD) in Spain based on consensus amongst clinicians and administrators., Methods: A two-round modified Delphi questionnaire was sent to clinicians (pulmonologists and GPs) and administrators, all experts in COPD. The scientific committee developed the statements and selected the participating experts. Four areas were explored: diagnosis, training, treatment, and clinical management. Panellists' agreement was assessed using a 9-point Likert scale, with scores of 1 to 3 indicating disagreement and 7 to 9, agreement. Consensus was considered to exist when 70% of the participants agreed or disagreed with the statement., Results: Respective response rates for the first and second round were 68% and 91% for clinicians, and 60% and 100% for administrators. The statements attracting the highest degree of consensus were: "Not enough nursing resources (time, staff, duties) are allocated for performing spirometry" (85.3% clinicians; 75% administrators); "Nurses need specific training in COPD" (84.8% clinicians; 100% administrators); "Rehabilitation programs are necessary for treating patients with COPD" (94.1% clinicians; 91.7% administrators); and "Integrated care processes facilitate the deployment of educational programs on COPD" (79.4% clinicians; 83.3% administrators)., Conclusions: This document can inform the development and implementation of specific initiatives addressing the existing obstacles in COPD management., What's Known: COPD is a prevalent and underdiagnosed disease that causes substantial morbidity and mortality. The National COPD Strategy established objectives and work programmes to apply in Spain. There are barriers impeding the application of interventions contemplated in the COPD strategy., What's New: Different agents involved in COPD management agree that the main challenges to improve COPD management are resource shortages in primary care nursing and lack of training in the use of COPD clinical guidelines. Clinicians and administrators involved in COPD management support the implementation of urgent measures to tackle the underdiagnosis of COPD, especially in primary care, along with the routine inclusion of respiratory rehabilitation programmes for COPD., (© 2021 John Wiley & Sons Ltd.)

Aims: The aim of this study was to quantify diagnostic inertia (DI) when the physician fails to diagnose hypertension and determine its associated factors., Methods: This cross-sectional, observational study involved all patients without a diagnosis of hypertension who had their blood pressure (BP) measured at least three times during the second half of 2010 (N = 48,605). Patients with altered mean BP figures (≥ 140/90 mmHg) were considered to experience DI. Secondary variables: gender, atrial fibrillation, diabetes mellitus, dyslipidemia, cardiovascular disease, age and the physician having attended a cardiovascular training course (ESCARVAL). Associated factors were assessed by multivariate logistic regression analysis., Results: Diagnostic inertia was present in 6450 patients (13.3%, 95% CI: 13.0-13.6%). Factors significantly associated with DI were: male gender (OR = 1.46, 95% CI: 1.37-1.55, p < 0.001), atrial fibrillation (OR = 0.73, 95% CI: 0.58-0.92, p = 0.007), the ESCARVAL cardiovascular course (OR = 0.88, 95% CI: 0.81-0.96, p = 0.005), diabetes mellitus (OR = 0.93, 95% CI: 0.87-0.99, p = 0.016), cardiovascular disease (OR = 0.77, 95% CI: 0.67-0.88, p < 0.001) and older age (years) (18-44→OR = 1; 45-59→OR = 12.45, 95% CI: 11.11-13.94; 60-74→OR = 18.11, 95% CI: 16.30-20.12; ≥ 75→OR = 20.43, 95% CI: 18.34-22.75; p < 0.001). The multivariate model had an area under the ROC curve of 0.81 (95% CI: 0.80-0.81, p < 0.001)., Conclusions: This study will help clinical researchers differentiate between the two forms of DI (interpretation of a positive screening test and interpretation of positive diagnostic criteria). The results found here in patients with hypertension suggest that this problem is prevalent, and that a set of associated factors can explain the outcome well (AUC>0.80)., (© 2016 John Wiley & Sons Ltd.)

Background: Delphi technique allows developing a multidisciplinary consensus to establish solutions., Aim: To identify barriers and solutions to improve control in patients with Type-2 Diabetes Mellitus (DM2)., Methods: An observational study using the 2-round Delphi technique (June-August 2011). A panel of 108 experts in DM2 from medical and nursing fields (primary care providers and specialists) from different regions completed via email a questionnaire with 41 Likert statements and 9 scores for each one. Level of agreement was assessed using measures of central tendency and dispersion. We analysed commonalities/differences between the two groups (Kappa index and McNemar chi-square)., Results: Response rate: 65%. Degree of agreement: 63.4% (95% CI 48.7-78.1%) in medicine, and 78.1% (95% CI 65.4-90.8) in nursing (p > 0.05). Overall level of agreement: Kappa = 0.43, (χ(2) = 2.5 p > 0.05). Regarding non-compliance with therapy, it improves with: the information to the partner/family/caregiver, patient education degree in diabetes, patient motivation and ability to share and agree on decisions with the patient. Clinical inertia improves with: motivation degree of healthcare professionals and the calculation of cardiovascular risk; and gets worse with: the shortage of time in consultation, absence of data in medical record, border high limits measurements accepted as normal readings, lack of a treatment goals, lack of teamwork (Physician/Nurse), scarcity of resources and lack of alarm systems in the electronic medical record on goals to achieve., Conclusion: The participants achieved an agreement in interventions in non-therapeutic compliance and clinical inertia to improve DM2 control., (© 2013 John Wiley & Sons Ltd.)

Objectives: To evaluate three different strategies (without or with mydriasis) for community based screening for sight threatening diabetic retinopathy (STDR)., Design: A masked cross-sectional comparative study., Setting: Primary care centre., Participants: 216 type-1 and type-2 diabetic patients (432 eyes)., Interventions: Screening for STDR was performed with the Topcon CRW6S non-mydriatic camera (NMC), compared with the grading of the seven-field standard stereoscopic photographs, 30 degrees field photographs with mydriasis as the gold standard method. Three fields were studied: Field 1 centred on the macula; field 2 centred on the disc and the macula and field 3 centred on the disc, on the macula and temporal upper to the macula all without and with mydriasis., Main Outcome Measures: Sensitivity and specificity of screening method and prevalence of STDR. Strategies: field 1 (macular), addition of field 2 (nasal), addition of field 3 (superior temporal) all without and with mydriasis., Results: The prevalence of STDR was 14.3%. When screening without mydriasis is performed, the percentage of referred patients increases from 14% (STDR) to almost 33% because of ungradable photographs. Sensitivity of detection of STDR by NMC using single field with mydriasis was 82% (95% confidence interval 72-92%) and without mydriasis 67% (54-80%). Specificity was 99% (97-100%) for single field with mydriasis and 99% (98-100%) without mydriasis. Sensitivity of detection using two fields with mydriasis was 95% (89-100%); without mydriasis (54-80%), slightly better than single field with mydriasis (72-92%). Specificity was similar., Conclusions: Screening for STDR with NMC can be performed effectively with one non-stereoscopic retinal photograph per eye with mydriasis using tropicamide 0.5%. Screening without mydriasis increases the number of patients to be referred.

To evaluate the level and factors affecting control of diabetes and cardiovascular risk factors in type 2 diabetes (TYPE 2 DM) patients. Multicentre cross-sectional study: a sample of 430 primary care practices across Spain selected 1907 type 2 diabetic patients. The first five consecutive ambulatory patients with TYPE 2 DM were eligible for the inclusion into the survey. Patients were free of known cardiovascular disease (CVD). Control criteria were defined based on 2002 American Diabetes Association (ADA) clinical practice recommendations. A total of 1907 patients (51% women) aged 63 +/- 9 years. Smoking prevalence was 22.6%, 50.6% had levels of A1c < 7%. Mean blood pressure (BP) was 148 +/- 17/86 +/- 10 mmHg. Only 7.8% have achieved the target of BP < 130/80 mmHg. Among the 1180 patients (65%) treated for hypertension, this target was attained in only 4.4% of patients. A measurement for low-density lipoprotein (LDL) cholesterol was available in 1669 patients (88%). Only 5.9% of patients achieved the target of LDL < 100 mg/dl. Among the 638 patients (41.6%) on drug treatment for dyslipidaemia, this target was attained in only 5.6% of patients. Among type 2 diabetic patients in Spain the prevalence of cardiovascular risk factors is high. Control of glycaemia, smoking, BP and LDL are far from optimal despite the widespread use of guidelines for the management of diabetes and CVD. The application of published recommendations needs to be reinforced.