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Tackling climate change and promoting sustainable development are two mutually reinforcing sides of the same coin; sustainable development will not be achieved without action against climate change. Conversely, many of the SDGs address the drivers of climate change.My school has designed and implemented a project called “An interplanetary travel” thanks to the collaboration of the ESERO Spain which provides us with a kit of materials for our purpose.The project is structured in different parts:-First, we ask our students what will happen if we do not take care of our planet today by recreating a radio program.Through a previous brainstorm the students consider the possibility of colonizing other planets of the Solar System in order to survive.-Second, to be able to choose the ideal future home, they must investigate various planets that match the requirements for the human being to live and do experiments in order to detect the existence of life.-Third, while some students are dedicated to designing and selling one-way tickets for this new place, through the creation of their own travel agency, and all the logistics involved others are dedicated to studying how to plan that trip . Subsequently, the "clients" select the agency that provides the best services.-Fourth, for the planning of the trip it is necessary that our students become spaceship engineers to design the space vehicle and the pertinent tests for its takeoff.To be able to build that spacecraft, it is necessary to investigate the different properties of the materials to find the perfect features that the different parts of the space vehicle must have: impact resistance, magnetism, densities, electrical properties and thermal conductivity, etc. and select the suitable ones to carry it out both the water rocket and the reentry capsule are designed and tested in an open field. The idea is to land in our future home.-Fifth, calculations are made for the different phases of our trip: launch phase, space phase and reentry phase. (Level adapted for high school students). For the reentry phase the parachute is designed and tested with an egg so that it can land without breaking.-Sixth, the students study the possible health consequences of future colonizers.For this we propose to design, through Arduino programming, an automatic irrigation of plants to be able to self-supply water and not waste it, making use of humidity sensors.-And finally, all student groups teach their peers the achievements through exhibitions.

Little is known about adult asthma patients' perspective of their disease burden. This study aimed to obtain a comprehensive picture of patient needs, evaluate their knowledge, source of information, and perception of the severity of their asthma, and compare these variables between severe (SA) and non-severe (NSA) asthma patients.We conducted an online cross-sectional survey in Spain among asthma patients aged ≥18 years. A bespoke questionnaire was used to collect sociodemographic data, asthma characteristics, treatments, disease burden, patient's perception of disease severity, and asthma information sources. Patients were classified as SA and NSA according to GINA 2020 treatment steps recommendations. To compare populations, 600 participants (200 SA and 400 NSA) were randomly selected to complete the survey.Participants were mostly women, mean age38 years. SA patients underestimated the severity of their asthma; 52% judged it as mild, and only 2% considered their asthma severe. Overall, 50% of NSA and 96% of SA patients had experienced ≥1 exacerbation the previous year (p 0.001). Fewer asthma exacerbations (SA) and improved quality of life (QoL) (NSA) were the most frequently expected therapy outcomes. NSA patients believe that asthma impacts their daily life (37%) and worsens QoL (34%) to a lesser degree than SA (67% and 59%, respectively; p 0.001). Patient-preferred sources of information were specialists (NSA:42%; SA: 38%) and primary care physicians (NSA: 41%; SA: 33%).Despite the effective therapies currently available, the results of this study still show a significant emotional burden and QoL impairment in patients with severe asthma.

Background: Hospital at home (HaH), either admission avoidance (AA) or early supported discharge (ESD), was increasingly implemented in Catalonia (7.7 M, Spain) for selected patients, achieving regional adoption within the 2011-2015 Health Plan. This study aimed to assess population-wide HaH outcomes over five years (2015-2019) in a consolidated regional HaH program and provide context-independent recommendations for service quality assurance. Methods: A mixed-methods approach was adopted, combining population-based retrospective analyses of registry information with qualitative research. AA and ESD were separately compared with conventional hospitalization groups using propensity score matching techniques. In the analysis, we evaluated the 12-month period before the acute episode, the admission, and use of healthcare resources at 30 and 90 days after discharge. A panel of experts discussed the results and provided recommendations for monitoring HaH services. Results: The adoption of AA steadily increased from 5,185 to 8,086 episodes/year (total episodes 31,901; mean age 73 (SD 17) years; 79% high-risk patients), whereas ESD remained stable over the study period, averaging 5,329 episodes per year (total episodes 26,646; mean age 68 (SD 16) years; 71% high-risk patients). Mortality rates were similar in HaH and conventional hospitalization within the episode (AA: 0.31% vs. 0.45%; ESD: 0.18% vs. 0.45%) and at 30-days (AA: 3.94% vs. 3.24%; ESD: 4.50% vs. 4.07%). Likewise, the frequency of patients requiring hospital re-admissions or ER visits 30 days after discharge was similar in HaH (AA and ESD) and the corresponding controls. The 27 healthcare providers assessed showed high variability in patients age, multimorbidity, severity of episodes, recurrences, and length of stay of AA episodes. Recommendations aiming at enhancing service delivery were produced. Conclusions: Besides confirming safety and value generation of AA, we found that this service is delivered in a case-mix of diferent scenarios, encouraging provider-profiled monitoring of the service, particularly for ESD modalities. Keywords: Hospital at Home, Admission Avoidance, Early Supported Discharge, Implementation Science, Integrated Care.

BackgroundMany advantages of hospital at home (HaH), as a modality of acute care, have been highlighted, but controversies exist regarding the cost-benefit trade-offs.ObjectiveTo assess health outcomes and analytical costs of hospital avoidance (HaH-HA) in a consolidated service with over ten years of delivery of HaH in Barcelona (Spain).MethodsA retrospective cost-consequence analysis of all first episodes of HaH-HA, directly admitted from the emergency room (ER) in 2017–2018, was carried out. HaH-HA was compared with a propensity-score-matched group of contemporary patients admitted to conventional hospitalization (Controls). Mortality, re-admissions, ER visits, and direct healthcare costs were evaluated.RegistrationClinicalTrials.gov(26/04/2017;NCT03130283).ResultsHaH-HA and Controls (n=441 each) were comparable in terms of age (73 [SD16]vs74 [16]), gender (male, 57%vs59%), multimorbidity, healthcare expenditure during the previous year, case mix index of the acute episode, and main diagnosis at discharge. HaH-HA presented lower mortality during the episode (0 vs. 19 (4.3%);p< 0.001). At 30 days post-discharge, HaH-HA and Controls showed similar re-admission rates; however, ER visits were lower in HaH-HA than in Controls (28 (6.3%) vs 34 (8.1%); p = 0.044). Average costs per patient during the episode were lower in the HaH-HA group (€ 1,078) than in Controls (€ 2,171). Likewise, healthcare costs within the 30 days post-discharge were also lower in HaH-Ha than in Controls (p< 0.001).ConclusionsThe study showed higher performance and cost reductions of HaH-HA in a real-world setting. The identification of sources of savings facilitates scaling of hospital avoidance.FundingThis article was funded by JADECARE project- HP-JA-2019 - Grant Agreement nº951442 (2020-2023), a European Union’s Health Program 2014-2020.KEY POINTSHospital at home, modality hospital avoidance, shows high potential for value generation in real-world settings by improving health outcomes and generating cost-savings.Positive outcomes of hospital avoidance seem associated to adequate management change and digital support.

Home hospital (HH) care is hospital-level substitutive care delivered at home for acutely ill patients who traditionally would be cared for in the hospital. Despite HH care programs operating successfully for years and scientific evidence of similar or better outcomes compared with bricks-and-mortar care, HH care outcomes in the United States for respiratory disease have not been evaluated.Do outcomes differ between patients admitted to HH care with acute respiratory illness vs those with other acute general medical conditions?This was a retrospective evaluation of prospectively collected data of patients admitted to HH care (2017-2021). We compared patients requiring admission with respiratory disease (asthma exacerbation [26%], acute exacerbation of COPD [33%], and non-COVID-19 pneumonia [41%]) to all other patients admitted to HH care. During HH care, patients received two nurse and one physician visit daily, IV medications, advanced respiratory therapies, and continuous heart and respiratory rate monitoring. Main outcomes were acute and postacute health-care use and safety.We analyzed 1,031 patients; 24% were admitted for respiratory disease. Patients with and without respiratory disease were similar: mean age, 68 ± 17 years, 62% women, and 48% White. Patients with respiratory more often were active smokers (21% vs 9%; P .001). Eighty percent of patients showed an FEVHH care is as safe and effective for patients with acute respiratory disease as for those with other acute general medical conditions. If scaled, it can generate significant high-value capacity for health systems and communities, with opportunities to advance the complexity of care delivered.

The objective of this workshop was to determine current nursing research priorities in critical care, adult pulmonary, and sleep conditions through input from consumer (patient, family, and formal and informal caregivers) and nursing experts around the world. Working groups composed of nurses and patients selected potential research priorities based on patient insight and a literature review of patient-reported outcomes, patient-reported experiences, and processes and clinical outcomes in the focal areas. A Delphi consensus approach, using a qualitative survey method to elicit expert opinion from nurses and consumers was conducted. Two rounds of online surveys available in English, Spanish, and Chinese were completed. A 75% or greater threshold for endorsement (combined responses from nursing and consumer participants) was determined a priori to retain survey items. A total of 837 participants (649 nurses and 188 patients, family, and/or caregivers) from 45 countries responded. Survey data were analyzed and nursing research priorities that comprise 23 critical care, 45 adult pulmonary, and 16 sleep items were identified. This project was successful in engaging a wide variety of nursing and consumer experts, applying a patient-reported outcome/patient-reported experience framework for organizing and understanding research priorities. The project outcome was a research agenda to inform, guide, and aid nurse scientists, educators, and providers, and to advise agencies that provide research and program funding in these fields.

Rationale: Pulmonary clinicians and patients anecdotally report barriers to home supplemental oxygen services including inadequate supply, unacceptable portable options, and equipment malfunction. Limited evidence exists to describe or quantify these problems.Objectives: To describe the frequency and type of problems experienced by supplemental oxygen users in the United States.Methods: The Patient Supplemental Oxygen Survey, a self-report questionnaire, was posted on the American Thoracic Society Public Advisory Roundtable and patient and health care–affiliated websites. Respondents were invited to complete the questionnaire, using targeted e-mail notifications. Data were analyzed using descriptive statistics, paired t tests, and χ2 analysis.Results: In total, 1,926 responses were analyzed. Most respondents reported using oxygen 24 h/d, for 1–5 years, and 31% used high flow with exertion. Oxygen use varied, with only 29% adjusting flow rates based on oximeter readings. The majority (65%) reported not hav...

Background Home hospitalization is widely accepted as a cost-effective alternative to conventional hospitalization for selected patients. A recent analysis of the home hospitalization and early discharge (HH/ED) program at Hospital Clínic de Barcelona over a 10-year period demonstrated high levels of acceptance by patients and professionals, as well as health value-based generation at the provider and health-system levels. However, health risk assessment was identified as an unmet need with the potential to enhance clinical decision making. Objective The objective of this study is to generate and assess predictive models of mortality and in-hospital admission at entry and at HH/ED discharge. Methods Predictive modeling of mortality and in-hospital admission was done in 2 different scenarios: at entry into the HH/ED program and at discharge, from January 2009 to December 2015. Multisource predictive variables, including standard clinical data, patients’ functional features, and population health risk assessment, were considered. Results We studied 1925 HH/ED patients by applying a random forest classifier, as it showed the best performance. Average results of the area under the receiver operating characteristic curve (AUROC; sensitivity/specificity) for the prediction of mortality were 0.88 (0.81/0.76) and 0.89 (0.81/0.81) at entry and at home hospitalization discharge, respectively; the AUROC (sensitivity/specificity) values for in-hospital admission were 0.71 (0.67/0.64) and 0.70 (0.71/0.61) at entry and at home hospitalization discharge, respectively. Conclusions The results showed potential for feeding clinical decision support systems aimed at supporting health professionals for inclusion of candidates into the HH/ED program, and have the capacity to guide transitions toward community-based care at HH discharge.

Background Comprehensive assessment of integrated care deployment constitutes a major challenge to ensure quality, sustainability and transferability of both healthcare policies and services in the transition toward a coordinated service delivery scenario. To this end, the manuscript articulates four different protocols aiming at assessing large-scale implementation of integrated care, which are being developed within the umbrella of the regional project Nextcare (2016–2019), undertaken to foster innovation in technologically-supported services for chronic multimorbid patients in Catalonia (ES) (7.5 M inhabitants). Whereas one of the assessment protocols is designed to evaluate population-based deployment of care coordination at regional level during the period 2011–2017, the other three are service-based protocols addressing: i) Home hospitalization; ii) Prehabilitation for major surgery; and, iii) Community-based interventions for frail elderly chronic patients. All three services have demonstrated efficacy and potential for health value generation. They reflect different implementation maturity levels. While full coverage of the entire urban health district of Barcelona-Esquerra (520 k inhabitants) is the main aim of home hospitalization, demonstration of sustainability at Hospital Clinic of Barcelona constitutes the core goal of the prehabilitation service. Likewise, full coverage of integrated care services addressed to frail chronic patients is aimed at the city of Badalona (216 k inhabitants). Methods The population-based analysis, as well as the three service-based protocols, follow observational and experimental study designs using a non-randomized intervention group (integrated care) compared with a control group (usual care) with a propensity score matching method. Evaluation of cost-effectiveness of the interventions using a Quadruple aim approach is a central outcome in all protocols. Moreover, multi-criteria decision analysis is explored as an innovative method for health delivery assessment. The following additional dimensions will also be addressed: i) Determinants of sustainability and scalability of the services; ii) Assessment of the technological support; iii) Enhanced health risk assessment; and, iv) Factors modulating service transferability. Discussion The current study offers a unique opportunity to undertake a comprehensive assessment of integrated care fostering deployment of services at regional level. The study outcomes will contribute refining service workflows, improving health risk assessment and generating recommendations for service selection. Trials registration NCT03130283 (date released 04/06/2018), NCT03768050 (date released 12/05/2018), NCT03767387 (date released 12/05/2018). Electronic supplementary material The online version of this article (10.1186/s12913-019-4174-2) contains supplementary material, which is available to authorized users.

The Glittre Activities of Daily Living Test (ADL-Test) is a reliable functional status measurement for stable chronic obstructive pulmonary disease (COPD) patients in a laboratory setting. We aimed to adapt the test to the home setting (mADL-Test) and to follow-up the functional status recovery of post-exacerbation COPD patients included in a home hospitalization (HH) program.We assessed 17 exacerbated moderate-to-very-severe COPD patients in 3 home visits: at discharge to HH (V0), 10days (V10post) and 1month after discharge (V30post). Patients completed the mADL-Test (laps, VO2 and VE), COPD assessment test (CAT), London Chest ADL Test (LCADL), modified Medical Research Council (mMRC) and upper limb strength (handgrip).The number of laps of the mADL-Test (4, 5 and 5, P.05), CAT (19, 12 and 12, P.01), mMRC (2, 1.5 and 1, P.01) and the self-care domain of the LCADL (6, 5 and 5, P.01) improved during follow-up (V0, V10post and V30post, respectively). No significant changes were evidenced in VO2, VE or handgrip.Our results suggest that the mADL-test can be performed in the home setting after a COPD exacerbation, and that functional status continues to improve 10days after discharge to HH.

Resumen Introduccion La prueba de actividades de la vida diaria de Glittre (prueba ADL) es, en un entorno de laboratorio, una medida fiable del estado funcional de los pacientes con enfermedad pulmonar obstructiva cronica (EPOC) estable. Nos propusimos adaptar la prueba para poder llevarla a cabo en el entorno domiciliario (test ADLm) y supervisar la recuperacion del estado funcional de pacientes con EPOC despues de una exacerbacion atendida en un programa de hospitalizacion domiciliaria (HD). Metodo Evaluamos a 17 pacientes con EPOC moderada a muy grave despues de una exacerbacion en 3 visitas domiciliarias: el dia del alta de HD (V 0 ), al cabo de 10 dias (V 10post ) y un mes despues del alta (V 30post ). Los pacientes realizaron la prueba ADLm (vueltas VO 2 y VE), impacto de la EPOC (CAT), el Cuestionario de disnea para las ADV London Chest (LCADL), la escala de disnea Medical Research Council modificada (MRCm) y una dinamometria de las extremidades superiores (fuerza de prension). Resultados el numero de vueltas al circuito en la prueba ADLm (4, 5 y 5, p 0 , V 10post y V 30post , respectivamente). No se constataron cambios significativos en el VO 2 , el VE o la fuerza de prension. Conclusion Nuestros resultados indican que, tras una exacerbacion de la EPOC, es factible realizar la prueba ADLm en el entorno domiciliario, y que el estado funcional continua mejorando 10 dias despues del alta de HD.

© 2020 IEEE. Personal use of this material is permitted. Permission from IEEE must be obtained for all other uses, in any current or future media, including reprinting /republishing this material for advertising or promotional purposes, creating new collective works, for resale or redistribution to servers or lists, or reuse of any copyrighted component of this work in other works Home hospitalization (HH) is presented as a healthcare alternative capable of providing high standards of care when patients no longer need hospital facilities. Although HH seems to lower healthcare costs by shortening hospital stays and improving patient's quality of life, the lack of continuous observation at home may lead to complications in some patients. Since blood tests have been proven to provide relevant prognosis information in many diseases, this paper analyzes the impact of different sampling methods on the prediction of HH outcomes. After a first exploratory analysis, some variables extracted from routine blood tests performed at the moment of HH admission, such as hemoglobin, lymphocytes or creatinine, were found to unmask statistically significant differences between patients undergoing successful and unsucessful HH stays. Then, predictive models were built with these data, in order to identify unsuccessful cases eventually needing hospital facilities. However, since these hospital admissions during HH programs are rare, their identification through conventional machine-learning approaches is challenging. Thus, several sampling strategies designed to face class imbalance were herein overviewed and compared. Among the analyzed approaches, over-sampling strategies, such as ROSE (Random Over-Sampling Examples) and conventional random over-sampling, showed the best performances. Nevertheless, further improvements should be proposed in the future so as to better identify those patients not benefiting from HH

More than 1.5 million adults in the United States use supplemental oxygen for a variety of respiratory disorders to improve their quality of life and prolong survival. This document describes recommendations from a multidisciplinary workshop convened at the ATS International Conference in 2017 with the goal of optimizing home oxygen therapy for adults. Ideal supplemental oxygen therapy is patient-specific, provided by a qualified clinician, includes an individualized prescription and therapeutic education program, and offers oxygen systems that are safe, promote mobility, and treat hypoxemia. Recently, patients and clinicians report a growing number of problems with home oxygen in the United States. Oxygen users experience significant functional, mechanical, and financial problems and a lack of education related to their oxygen equipment-problems that impact their quality of life. Health care providers report a lack of readily accessible resources needed to prescribe oxygen systems correctly and efficiently. Patients with certain lung diseases are affected more than others because of physically unmanageable or inadequate portable systems. Analysis is needed to quantify the unintended impact that the Centers for Medicare and Medicaid Services Competitive Bidding Program has had on patients receiving supplemental oxygen from durable medical equipment providers. Studies using effectiveness and implementation research designs are needed to develop and evaluate new models for patient education, identify effective ways for stakeholders to interface, determine the economic benefit of having respiratory therapists perform in-home education and follow-up testing, and collaborate with technology companies to improve portable oxygen devices. Generation of additional evidence of the benefit of supplemental oxygen across the spectrum of advanced lung diseases and the development of clinical practice guidelines should both be prioritized.

Introduction : Pulmonary hypertension (PH) is a rare, life-threating disease that requires complex long term management, often involving coordination of actions across different agencies and jurisdictions. This is a challenging scenario to the effective delivery of care. Adoption of an integrated care (IC) approach with a sensible use of enabling technology can be a way of successfully dealing with this complexity. Aims : a) To assess the usability and potential feasibility in clinical practice of the Nabelia mHealthCare Platform, in the IC management of patients with Pulmonary Hypertension and; b) to identify areas in need of improvement in collaboration with patients and professionals Material and method : This qualitative research study involved two distinct groups chosen for convenience: 1) Patients’ group, patients with a pulmonary arterial hypertension (HAP) diagnose and/or chronic thromboembolic hypertension (HPTEC); and, 2) Health professionals’ group. In both groups, we carried out : 1) user tests followed by administration of a questionnaire (adaptation of the SUMI questionnaire items); 2) Focus groups sessions (1 patients, 1 professionals). A total of 23 people participated in this study (12 patients, 7 practitioners and 4 nurses). Informed consent was obtained from all participants. The study was completed by a heuristic assessment of the platform that was undertaken by a specially trained researcher. Results : Professionals highlighted that the Platform facilitated: 1) the sharing of information (notably in the case of treatment prescribed), 2) coordination of actions (remote monitoring data) and 3) communication with patients. Patients’ appraisals of the platform differed. Globally, it was viewed as an interesting tool and patients especially valued the accessibility to the information about their condition and the easiness to share this information with the different health professionals. Perceptions on the benefits of using the mobile application to manage everyday life depended on patients’ age and treatments’ complexity. Thus, younger patients were more favorable towards its use while elders were more reluctant. Heuristic evaluation. The aspects that were best ranked where those related with the clarity of the interface (adequate management of spaces and text, visual structure of the information, easily recognizable links), consistency in its design (elements, actions, language, navigation), and architecture (organizational system, elements and terms used in the navigation menu). Usability elements in need of attention were those related with system status, information flow, aid in its actions, clarity of information, control by user, readability and configuration. The application is easy to learn and uses standard tags and a language close to professionals with helpful graphics though in some parts readability could be improved. Control of the application by the user was acceptable at the current status of development. Conclusions : At its current stage of development the Nabelia mHealthCare Platform has a good usability and can be potentially applied in the management of patients with pulmonary hypertension. Professionals and patients think that the application facilitates the management of the disease, allows closer follow-up and monitoring and improves coordination across levels of health care. Attention to acceptance and usability issues in the group of older patients is, however, required.

BackgroundClinical management of patients with chronic obstructive pulmonary disease (COPD) shows potential for improvement provided that patients’ heterogeneities are better understood. The study addresses the impact of comorbidities and its role in health risk assessment.ObjectiveTo explore the potential of health registry information to enhance clinical risk assessment and stratification.DesignFixed cohort study including all registered patients with COPD in Catalonia (Spain) (7.5 million citizens) at 31 December 2014 with 1-year (2015) follow-up.MethodsA total of 264 830 patients with COPD diagnosis, based on the International Classification of Diseases (Ninth Revision) coding, were assessed. Performance of multiple logistic regression models for the six main dependent variables of the study: mortality, hospitalisations (patients with one or more admissions; all cases and COPD-related), multiple hospitalisations (patients with at least two admissions; all causes and COPD-related) and users with high healthcare costs. Neither clinical nor forced spirometry data were available.ResultsMultimorbidity, assessed with the adjusted morbidity grouper, was the covariate with the highest impact in the predictive models, which in turn showed high performance measured by the C-statistics: (1) mortality (0.83), (2 and 3) hospitalisations (all causes: 0.77; COPD-related: 0.81), (4 and 5) multiple hospitalisations (all causes: 0.80; COPD-related: 0.87) and (6) users with high healthcare costs (0.76). Fifteen per cent of individuals with highest healthcare costs to year ratio represented 59% of the overall costs of patients with COPD.ConclusionsThe results stress the impact of assessing multimorbidity with the adjusted morbidity grouper on considered health indicators, which has implications for enhanced COPD staging and clinical management.Trial registration numberNCT02956395.

Despite well established clinical guidelines, performance of long-term oxygen therapy (LTOT) programs shows marked variability among territories. The current study assessed the LTOT program and the health status of patients on LTOT prior to the deployment of community-based integrated care in an urban health district of Barcelona (Spain).To assess: i) the LTOT program and health status of the patients on LTOT in the health district; ii) their frailty profile; and, iii) the requirements for effective deployment of integrated care services for these patients.Cross-sectional observational study design including all patients (n = 406) on LTOT living in the health district. Health status, frailty, arterial blood gases, forced spirometry and hand-grip muscle strength were measured. Network analysis of frailty was carried out.Adequacy of LTOT prescription (n = 362): 47% and 31% of the patients had PaO2 ≤ 60 mmHg and ≤55 mmHg, respectively. Adherence to LTOT: 31% of all patients used LTOT ≥15 h/d; this figure increased to 67% in those with PaO2≤60 mmHg. Assessment of frailty: Overall, LTOT patients presented moderate to severe frailty. Care complexity was observed in 42% of the patients.Adequacy and adherence to LTOT was poor and many patients were frail and complex. The outcomes of the network analysis may contribute to enhance assessment of frailty in LTOT patients. These observations suggest that an integrated care strategy has the potential to improve the health outcomes of these patients.

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.

COPD exacerbations worsen quality of life and increase cost. There is evidence of the impact of non-pharmacological treatment in the prevention of exacerbations. Therapeutic Education Programs (TEP) is a key component in the Integrated Care Models (ICM). To evaluate the effectiveness of TEP in preventing exacerbations after discharge. RCT (1:1), 6-m follow-up. Two hospitals: a) exclusively TEP and b) TEP as part of ICM. Recruitment: 12 m. Assessment using 5 domains (WHO). At 6 m we evaluated hospital admissions, emergency room visits and mortality. Intervention: 5 TEP group sessions. Material: “Controlling COPD”. 223 p (FEV 1 (44.7% (17) pred, 121 controls (CG) and 112 intervention (IG)). Age 73.3 (9.3), 17% smokers. Charlson index 5.2 (7.9), 45% LTOT. No differences between groups and centres at baseline. At 3 m (Hospital admission (23.5%), Emergency room visits (25.5%) exitus (6.2%)). The joint analysis of both centres showed a decrease in emergency room visits and hospital admissions, in comparison with the CG group, although it was not significant. When the two groups were analyzed separately, the patients in the IG with exclusive TEP showed no differences in emergency room visits and hospital admissions. Patients in the IG with TEP as part of an ICM showed a decrease in the number of emergency room visits (p=0.001) compared to the CG. The number of hospital admissions did not decrease but we observed a change in the management and type of admission, with 80% of the admissions being programmed (directly from home to ward). TEP by itself has no impact on the use of health resources. The assessment proposed by the WHO, is useful for COPD.Partially supported by SEPAR (191/2013).

Educational Aims To explain the basic principles of telemedicine applicable to chronic respiratory diseases To review telemedicine interventions for patients with chronic respiratory diseases To outline the advantages and limitations (including cost and barriers to implementation) of telemedicine for patients with chronic respiratory diseases To propose recommendations for clinical management of patients receiving telemedicine for chronic respiratory diseases

The mechanisms and time course of the pulmonary gas exchange response to 100% O(2) breathing in acute respiratory failure needing mechanical ventilation were studied in eight patients with acute lung injury (ALI) (48 +/- 18 yr [mean +/- SD]) and in four patients (66 +/- 2 yr) with chronic obstructive pulmonary disease (COPD). We postulated that, in patients with ALI while breathing 100% O(2), the primary mechanism of hypoxemia, i.e., increased intrapulmonary shunt, would further worsen (increase) as a result of reabsorption atelectasis. Respiratory and inert gases, and systemic and pulmonary hemodynamics were measured at maintenance fraction of inspired oxygen (FI(O(2))-m), at 30 and 60 min while breathing 100% O(2), and then at 30 min of resuming FI(O(2))-m. During 100% O(2) breathing, in patients with ALI, Pa(O(2)) (by 207 and 204 mm Hg; p < 0.01 each), Pa(CO(2)) (by 4 mm Hg each) (p < 0.05 each), and intrapulmonary shunt (from 16 +/- 10% to 22 +/- 11% and 23 +/- 11%) (p < 0.05 each) increased respectively. By contrast, in patients with COPD, Pa(O(2)) (by 387 and 393 mm Hg; p < 0.001 each), Pa(CO(2)) (by 4 and 5 mm Hg) and the dispersion of pulmonary blood flow (log SDQ) (from 1.33 +/- 0.10 to 1.60 +/- 0.20 and 1.80 +/- 0.30 [p < 0.05]) increased, respectively. In patients with ALI, the breathing of 100% O(2) deteriorates intrapulmonary shunt owing to collapse of unstable alveolar units with very low ventilation-perfusion (V A/Q) ratios, as opposed to patients with COPD, in whom only the dispersion of the blood flow distribution is disturbed, suggesting release of hypoxic pulmonary vasoconstriction.

Background It has been hypothesized that local release of prostacyclin in acute pneumonia may ablate hypoxic pulmonary vasoconstriction, thus contributing to the impairment of pulmonary gas exchange in these patients. Inhibition of cyclooxygenase pathway could prevent this phenomenon by reducing the release of these metabolites. Methods A study was designed to assess the effect of IV acetylsalicylic acid (ASA) (2 g) on pulmonary gas exchange in seven patients (age, 64±11 [mean±SD] years) with unilateral severe pneumonia (PaO2/fraction of inspired oxygen, 168 ±67) needing mechanical ventilation. Respiratory gases, pulmonary and systemic hemodynamics, and ventilation-perfusion ( V ˙ A / Q ˙ ) distributions were studied before and 15 and 60 min after the infusion of ASA. Results At baseline, the amount of shunt ( V ˙ A / Q ˙ ratios

To assess the risk and prognostic factors of community-acquired pneumonia occurring in the elderly (over age 65 yr) requiring hospitalization, two studies, case-control and cohort, were performed over an 8-mo period in a 1,000-bed university teaching hospital. We studied 101 patients with pneumonia (cases), age 78.5 +/- 7.9 yr (mean +/- SD). Each case was matched for sex, age (+/- 5 yr), and date of admission (+/- 2 d) with a control subject, without pneumonia during the preceding 3 yr, arriving at the emergency room. Etiologic diagnosis was obtained in 43 of 101 (42%) cases. The main microbial agents causing pneumonia were: Streptococcus pneumoniae (19 of 43, 44%), and Chlamydia pneumoniae (9 of 43, 21%). Gram-negative bacilli were uncommon (2 of 43, 5%). The multivariate analysis demonstrated that large-volume aspiration, and low serum albumin (< 30 mg/dl) were independent risk factors associated with the development of pneumonia. Crude mortality rate was 26% (26 of 101), while pneumonia-related mortality was 20% (20 of 101). The attributable mortality was 23% (odds ratio [OR]: 11.3; 95% confidence interval [CI]: 3.25 to 60.23; p < 0.0001). The multivariate analysis showed that patients had a worse prognosis if they were previously bedridden, had prior swallowing disorders, body temperature on admission was less than 37 degrees C, respiratory frequency was greater than 30/min or had three or more affected lobes on chest radiograph. Age by itself was not a significant factor related to prognosis. Among the significant risk factors, only nutritional status is probably amenable to medical intervention. The prognostic factors found in this study may help to identify, upon admission, those subjects at higher risk and who may require special observation.

Determine treatment adherence in patients with multiple chronic conditions (MCC).A random patient sample ≥ 15 years, discharged from hospital with ≥1 chronic conditions (CC) was interviewed after 6-12 months. Analysis included variables in 5 dimensions (WHO): socio-demographics, disease, treatment, patient and health system characteristics. Morisky-Green adherence questionnaire was used. High chronic treatment complexity was defined as:3 pills/day,6 inhalations/day,1 injection/day, pharmacological treatment plus diet or self-monitoring techniques.301 patients were interviewed (62 ± 15 years, 59% males). Despite good treatment information perception (79%), only 3% followed the patient education programme. Poor adherents (82%) were older (64 ± 14 years vs. 55 ± 16 years), had more CC (3.25 ± 2.02 vs. 2.62 ± 2.72), a higher frequency of hypertension (44% vs. 15%), ischaemic heart diseases: (21% vs. 4%), hyperlipidaemia (19% vs. 6%), more pills/day (5.78 ± 4.14 vs. 3.20 ± 4.70) and more complex treatments (95% vs. 70%) (p0.05). On multivariate analysis number of CC [3.68 (0.75-18.15)], pills/day [2.23 (1.02-4.84)], treatment complexity [4.00 (1.45-11.04)], and hypertension [2.57 (1.06-6.25)] were predictive of poor adherence (OR 95% CI p0.05).The WHO conceptual framework allows the construction of poor adherence risk profiles in patients with MCC after hospital discharge.Predictive variables of poor adherence could help clinicians detect patients with MCC most likely to present poor adherence.

Background: Chronic disorders constitute a primary concern because of their burden on healthcare systems worldwide. Integrated care strategies enhancing the interface between tertiary care and primary care are pivotal to improve chronic care. Aim: To asses the prevalence of chronic disorders on hospital discharges and their impact on unplanned admissions and mortality. Design: Cross-sectional analysis of discharge information over 1 year (2004) in one University hospital. Methods: Adoption of an operational definition of chronic disorder based on the WHO. Main outcome: co-morbid conditions, emergency room and hospital admissions, outpatient consultations and mortality. Results: Fifty-eight percent of patients presented at least one chronic condition (19 192 patients, 53% males, 63 ± 18 years) as primary (12 526 patients, 38%) or secondary diagnosis. The Charlson index was 2 ± 3. Each chronic condition was associated with a 30% increase of having had an admission in the previous year. Up to 9% (1 656) of chronic patients showed multiple admissions in the previous year: two (917 patients, 55%), three (360, 22%) and four or beyond (379, 23%), being mostly unscheduled hospitalizations. The three most prevalent chronic disorders were cancer, cardiovascular diseases and chronic obstructive pulmonary disease (COPD). The rate of admissions was associated with co-morbidity ( P < 0.001) and mortality ( P < 0.001). Conclusions: The study shows a high impact of cancer on planned hospitalizations whereas cardiovascular diseases and COPD generates a high percentage of unscheduled admissions. We conclude that integrated care services including patient-oriented guidelines are strongly needed to enhance both health and managerial outcomes.