Publications by authors named "Josep Roca"

148 Publications

The patient at the centre: evidence from 17 European integrated care programmes for persons with complex needs.

BMC Health Serv Res 2020 Nov 30;20(1):1102. Epub 2020 Nov 30.

Erasmus University Rotterdam, P.O.Box 1738, 3000, DR, Rotterdam, The Netherlands.

Background: As the prevalence of multi-morbidity increases in ageing societies, health and social care systems face the challenge of providing adequate care to persons with complex needs. Approaches that integrate care across sectors and disciplines have been increasingly developed and implemented in European countries in order to tackle this challenge. The aim of the article is to identify success factors and crucial elements in the process of integrated care delivery for persons with complex needs as seen from the practical perspective of the involved stakeholders (patients, professionals, informal caregivers, managers, initiators, payers).

Methods: Seventeen integrated care programmes for persons with complex needs in 8 European countries were investigated using a qualitative approach, namely thick description, based on semi-structured interviews and document analysis. In total, 233 face-to-face interviews were conducted with stakeholders of the programmes between March and September 2016. Meta-analysis of the individual thick description reports was performed with a focus on the process of care delivery.

Results: Four categories that emerged from the overarching analysis are discussed in the article: (1) a holistic view of the patient, considering both mental health and the social situation in addition to physical health, (2) continuity of care in the form of single contact points, alignment of services and good relationships between patients and professionals, (3) relationships between professionals built on trust and facilitated by continuous communication, and (4) patient involvement in goal-setting and decision-making, allowing patients to adapt to reorganised service delivery.

Conclusions: We were able to identify several key aspects for a well-functioning integrated care process for complex patients and how these are put into actual practice. The article sets itself apart from the existing literature by specifically focussing on the growing share of the population with complex care needs and by providing an analysis of actual processes and interpersonal relationships that shape integrated care in practice, incorporating evidence from a variety of programmes in several countries.
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http://dx.doi.org/10.1186/s12913-020-05917-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7706259PMC
November 2020

Health Outcomes from Home Hospitalization: Multisource Predictive Modeling.

J Med Internet Res 2020 10 7;22(10):e21367. Epub 2020 Oct 7.

Institute for Bioengineering of Catalonia (IBEC), Barcelona Institute of Science and Technology (BIST), Universitat Politècnica de Catalunya (UPC), CIBER-BBN, Barcelona, Spain.

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.
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http://dx.doi.org/10.2196/21367DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7578817PMC
October 2020

Integrated Care Intervention Supported by a Mobile Health Tool for Patients Using Noninvasive Ventilation at Home: Randomized Controlled Trial.

JMIR Mhealth Uhealth 2020 04 13;8(4):e16395. Epub 2020 Apr 13.

Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.

Background: Home-based noninvasive ventilation has proven cost-effective. But, adherence to therapy still constitutes a common clinical problem. We hypothesized that a behavioral intervention supported by a mobile health (mHealth) app could enhance patient self-efficacy. It is widely accepted that mHealth-supported services can enhance productive interactions among the stakeholders involved in home-based respiratory therapies.

Objective: This study aimed to measure changes in self-efficacy in patients with chronic respiratory failure due to diverse etiologies during a 3-month follow-up period after the intervention. Ancillary objectives were assessment of usability and acceptability of the mobile app as well as its potential contribution to collaborative work among stakeholders.

Methods: A single-blind, single-center, randomized controlled trial was conducted between February 2019 and June 2019 with 67 adult patients with chronic respiratory failure undergoing home-based noninvasive ventilation. In the intervention group, a psychologist delivered a face-to-face motivational intervention. Follow-up was supported by a mobile app that allowed patients to report the number of hours of daily noninvasive ventilation use and problems with the therapy. Advice was automatically delivered by the mobile app in case of a reported problem. The control group received usual care. The primary outcome was the change in the Self Efficacy in Sleep Apnea questionnaire score. Secondary outcomes included app usability, app acceptability, continuity of care, person-centered care, and ventilatory parameters.

Results: Self-efficacy was not significantly different in the intervention group after the intervention (before: mean 3.4, SD 0.6; after: mean 3.4, SD 0.5, P=.51). No changes were observed in adherence to therapy nor quality of life. Overall, the mHealth tool had a good usability score (mean 78 points) and high acceptance rate (mean score of 7.5/10 on a Likert scale). It was considered user-friendly (mean score of 8.2/10 on a Likert scale) and easy to use without assistance (mean score of 8.5/10 on a Likert scale). Patients also scored the perception of continuity of care and person-centered care as high.

Conclusions: The integrated care intervention supported by the mobile app did not improve patient self-management. However, the high acceptance of the mobile app might indicate potential for enhanced communication among stakeholders. The study identified key elements required for mHealth tools to provide effective support to collaborative work and personalized care.

Trial Registration: ClinicalTrials.gov NCT03932175; https://clinicaltrials.gov/ct2/show/NCT03932175.
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http://dx.doi.org/10.2196/16395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7186864PMC
April 2020

Cost-effectiveness of a technology-supported multimodal prehabilitation program in moderate-to-high risk patients undergoing lung cancer resection: randomized controlled trial protocol.

BMC Health Serv Res 2020 Mar 12;20(1):207. Epub 2020 Mar 12.

August Pi i Sunyer Biomedical Research Institute - IDIBAPS, University of Barcelona (UB), Barcelona, Spain.

Background: Multimodal prehabilitation is a preoperative intervention with the objective to enhance cancer patients' functional status which has been showed to reduce both postoperative morbidity and hospital length of stay in digestive oncologic surgery. However, in lung cancer surgery patients further studies with higher methodological quality are needed to clarify the benefits of prehabilitation. The main aim of the current protocol is to evaluate the cost-effectiveness of a multimodal prehabilitation program supported by information and communication technologies in moderate-to-high risk lung cancer patients undergoing thoracic surgery.

Methods: A Quadruple Aim approach will be adopted, assessing the prehabilitation program at the following levels: i) Patients' and professionals' experience outcomes (by means of standardized questionnaires, focus groups and structured interviews); ii) Population health-based outcomes (e.g. hospital length of stay, number and severity of postoperative complications, peak oxygen uptake and levels of systemic inflammation); and, iii) Healthcare costs.

Discussion: This study protocol should contribute not only to increase the scientific basis on prehabilitation but also to detect the main factors modulating service adoption.

Trial Registration: NCT04052100 (August 9, 2019).
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http://dx.doi.org/10.1186/s12913-020-05078-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7068871PMC
March 2020

Class Imbalance Impact on the Prediction of Complications during Home Hospitalization: A Comparative Study.

Annu Int Conf IEEE Eng Med Biol Soc 2019 Jul;2019:3446-3449

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.
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http://dx.doi.org/10.1109/EMBC.2019.8857746DOI Listing
July 2019

Effects of Pulmonary Hypertension on Exercise Capacity in Patients With Chronic Obstructive Pulmonary Disease.

Arch Bronconeumol 2020 08 23;56(8):499-505. Epub 2019 Nov 23.

Department of Pulmonary Medicine, Hospital Clínic-Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Spain.

Introduction: The impact of pulmonary hypertension (PH) on exercise tolerance in chronic obstructive pulmonary disease (COPD) has not been fully elucidated. It is necessary to characterize pulmonary hemodynamics in patients with moderate to severe COPD in order to improve their management. The aim of the study was to determine whether in COPD the presence of PH is associated with reduced exercise tolerance in a cohort of stable COPD patients.

Methods: Cross-sectional analysis of 174 COPD patients clinically stable: 109 without PH and 65 with PH (COPD-PH). We assessed socio-demographic data, lung function, quality of life, dyspnea, cardiopulmonary exercise testing (CPET), constant workload endurance time (CWET), and six-minute walk test (6MWT). We elaborated a logistic regression model to explore the impact of PH on exercise capacity in COPD patients.

Results: COPD-PH patients showed lower exercise capacity both at maximal (CPET) (43(20) versus 68(27) Watts and 50(19)% versus 71(18)% predicted peak oxygen consumption (VOpeak), COPD-PH and COPD, respectively), and at submaximal tests (6MWT) (382(94) versus 486(95) m). In addition, the COPD-PH group had lower endurance time than the non-PH COPD group (265(113) s and 295(164) s, respectively).

Conclusions: The presence of PH is an independent factor that impairs exercise capacity in COPD.
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http://dx.doi.org/10.1016/j.arbres.2019.10.015DOI Listing
August 2020

ERS Presidential Summit 2018: multimorbidities and the ageing population.

ERJ Open Res 2019 Jul 25;5(3). Epub 2019 Sep 25.

Coimbra University Hospital, Coimbra, Portugal.

As the average age of the population increases, so will the prevalence of chronic respiratory diseases and associated multimorbidity. This will result in a more complex clinical environment. Part of the solution will be to allow patients to be co-creators in the design of their care. It will also require clinicians to shift in their current approaches to care, step out of the disease- or pathology-oriented approach and embrace new ideas. In an effort to prepare the respiratory community for the challenge, we reflect on concepts to empower patients multidisciplinary systems, new technologies and transition from end-of-life care to advanced care planning.
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http://dx.doi.org/10.1183/23120541.00126-2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6759575PMC
July 2019

Digital Health Transformation of Integrated Care in Europe: Overarching Analysis of 17 Integrated Care Programs.

J Med Internet Res 2019 09 26;21(9):e14956. Epub 2019 Sep 26.

Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Universitat de Barcelona, Barcelona, Spain.

Background: Digital health tools comprise a wide range of technologies to support health processes. The potential of these technologies to effectively support health care transformation is widely accepted. However, wide scale implementation is uneven among countries and regions. Identification of common factors facilitating and hampering the implementation process may be useful for future policy recommendations.

Objective: The aim of this study was to analyze the implementation of digital health tools to support health care and social care services, as well as to facilitate the longitudinal assessment of these services, in 17 selected integrated chronic care (ICC) programs from 8 European countries.

Methods: A program analysis based on thick descriptions-including document examinations and semistructured interviews with relevant stakeholders-of ICC programs in Austria, Croatia, Germany, Hungary, the Netherlands, Norway, Spain, and the United Kingdom was performed. A total of 233 stakeholders (ie, professionals, providers, patients, carers, and policymakers) were interviewed from November 2014 to September 2016. The overarching analysis focused on the use of digital health tools and program assessment strategies.

Results: Supporting digital health tools are implemented in all countries, but different levels of maturity were observed among the programs. Only few ICC programs have well-established strategies for a comprehensive longitudinal assessment. There is a strong relationship between maturity of digital health and proper evaluation strategies of integrated care.

Conclusions: Notwithstanding the heterogeneity of the results across countries, most programs aim to evolve toward a digital transformation of integrated care, including implementation of comprehensive assessment strategies. It is widely accepted that the evolution of digital health tools alongside clear policies toward their adoption will facilitate regional uptake and scale-up of services with embedded digital health tools.
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http://dx.doi.org/10.2196/14956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6794072PMC
September 2019

Evaluation of integrated care services in Catalonia: population-based and service-based real-life deployment protocols.

BMC Health Serv Res 2019 Jun 11;19(1):370. Epub 2019 Jun 11.

Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.

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).
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http://dx.doi.org/10.1186/s12913-019-4174-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560864PMC
June 2019

Training-induced changes on quadriceps muscle oxygenation measured by near-infrared spectroscopy in healthy subjects and in chronic obstructive pulmonary disease patients.

Clin Physiol Funct Imaging 2019 Jul 13;39(4):284-290. Epub 2019 May 13.

Pulmonology Department, Hospital del Mar, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra (UPF), CIBERES (ISCIII), Barcelona, Spain.

Aim: We hypothesize that training-induced changes in muscle oxygen saturation (StO ) assessed by near-infrared spectroscopy (NIRS) during constant work rate cycling exercise (CWRE) may be a useful marker of the effects of training at 'vastus medialis' of the quadriceps in patients with chronic obstructive pulmonary disease (COPD).

Methods: Incremental exercise [peak oxygen uptake (VO )] and CWRE at 70% pretraining peak VO , before and after 8-w training, were done in 10 healthy age-matched subjects (H) [80% men, 65(11) years, FEV 105(14)%] and 16 COPD patients [94% men, 70(5) years, FEV 46(11) %] encompassing the entire spectrum of disease severity, recruited in the outpatient clinics. NIRS was used to assess StO in the 'vastus medialis' of the left quadriceps.

Results: Pretraining CWRE decreased StO (P<0·05) and generated marked StO rebound (P<0·001) after unloading in the two groups. After training, VO peak increased in H [253(204) ml min ] (P<0·01) and in COPD [180(183) ml·min ] (P = 0·01) and blood lactate fell [-4·4 (2·7) and -1·6(2·3) mmol·m ] (P<0·05 each). Training generated a further fall in StO during CWRE [-10(12)% and -10(10)%, P<0·05] and increased StO rebound after unloading [8(7)% and 5(9)%, P<0·05] in both groups.

Conclusion: Endurance training further decreased StO during CWRE, similarly in both groups, likely due to training-induced enhancement of muscle O transfer and utilization. Training-induced StO fall during CWRE may be useful individual marker for non-invasive assessment of enhanced muscle aerobic post-training function.
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http://dx.doi.org/10.1111/cpf.12572DOI Listing
July 2019

Survival and quality of life after surgery for colorectal cancer in the elderly: a comparative study.

Rev Esp Enferm Dig 2019 Mar;111(3):193-198

Hospital Germans Trias i Pujol.

Background: the aim of this study was to analyze the clinical results of the multidisciplinary management of elderly patients with colorectal cancer in a single center and to describe postoperative quality of life.

Methods: a comparative study was designed to compare the results and quality of life of patients treated in our center for colon cancer, aged from 80 to 84 years (study group) compared to a control group (aged form 75 to 79 years of age). Morbidity, mortality, oncological results and quality of life were analyzed.

Results: eighty-seven patients aged between 80 and 84 years of age (study group) were compared to a control group, which was formed by 91 patients aged from 75 to 79 years of age. There were no significant differences in technique and morbidity. Survival at 30 days, 90 days and at the end of follow-up (median 48 months) were similar in both groups. There were no differences in quality of life except for one item with regard to physical function (p = 0.0138).

Conclusion: similar clinical results and quality of life were achieved after treating elderly patients with colon cancer with a multidisciplinary management approach.
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http://dx.doi.org/10.17235/reed.2018.5807/2018DOI Listing
March 2019

Paradigm changes for diagnosis: using big data for prediction.

Clin Chem Lab Med 2019 02;57(3):317-327

Hospital Clínic, IDIBAPS, Facultat de Medicina, Universitat de Barcelona, Barcelona, Catalunya, Spain.

Due to profound changes occurring in biomedical knowledge and in health systems worldwide, an entirely new health and social care scenario is emerging. Moreover, the enormous technological potential developed over the last years is increasingly influencing life sciences and driving changes toward personalized medicine and value-based healthcare. However, the current slow progression of adoption, limiting the generation of healthcare efficiencies through technological innovation, can be realistically overcome by fostering convergence between a systems medicine approach and the principles governing Integrated Care. Implicit with this strategy is the multidisciplinary active collaboration of all stakeholders involved in the change, namely: citizens, professionals with different profiles, academia, policy makers, industry and payers. The article describes the key building blocks of an open and collaborative hub currently being developed in Catalonia (Spain) aiming at generation, deployment and evaluation of a personalized medicine program addressing highly prevalent chronic conditions that often show co-occurrence, namely: cardiovascular disorders, chronic obstructive pulmonary disease, type 2 diabetes mellitus; metabolic syndrome and associated mental disturbances (anxiety-depression and altered behavioral patterns leading to unhealthy life styles).
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http://dx.doi.org/10.1515/cclm-2018-0971DOI Listing
February 2019

Telehealth for patients with chronic obstructive pulmonary disease (COPD): a systematic review and meta-analysis protocol.

BMJ Open 2018 09 19;8(9):e021865. Epub 2018 Sep 19.

Servicio de Neumología, Hospital Clínic de Barcelona, Barcelona, Spain.

Introduction: Chronic obstructive pulmonary disease (COPD) is a highly prevalent chronic disease characterised by persistent respiratory symptoms. A focus of COPD interventional studies is directed towards prevention of exacerbations leading to hospital readmissions. Telehealth as a method of remote patient monitoring and care delivery may be implemented to reduce hospital readmissions and improve self-management of disease. Prior reviews have not systematically assessed the efficacies of various telehealth functionalities in patients with COPD at different stages of disease severity. We aim to evaluate which COPD telehealth interventions, classified by their functionalities, are most effective in improving patient with COPD management measured by both clinical and resource utilisation outcomes.

Methods And Analysis: We will conduct a systematic review which will include randomised controlled trials comparing the efficacy of telehealth interventions versus standard care in patients with COPD with confirmed disease severity based on forced expiratory volume(%) levels. An electronic search strategy will be used to identify trials published since 2000 in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, CINHAL. Telehealth is described as remote monitoring and delivery of care where patient data/clinical information is routinely or continuously collected and/or processed, presented to the patient and transferred to a clinical care institution for feedback, triage and intervention by a clinical specialist. Two authors will independently screen articles for inclusion, assess risk of bias and extract data. We will merge studies into a meta-analysis if the interventions, technologies, participants and underlying clinical questions are homogeneous enough. We will use a random-effects model, as we expect some heterogeneity between interventions. In cases where a meta-analysis is not possible, we will synthesise findings narratively. We will assess the quality of the evidence for the main outcomes using GRADE.

Ethics And Dissemination: Research ethics approval is not required. The findings will be disseminated through publication in a peer-reviewed journal.

Prospero Registration Number: CRD42018083671.
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http://dx.doi.org/10.1136/bmjopen-2018-021865DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6150147PMC
September 2018

Implementation of Home Hospitalization and Early Discharge as an Integrated Care Service: A Ten Years Pragmatic Assessment.

Int J Integr Care 2018 May 16;18(2):12. Epub 2018 May 16.

Hospital Clínic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en red, Enfermedades Respiratorias, University of Barcelona, Catalonia, ES.

Home Hospitalization has proven efficacy, but its effectiveness and potential as an Integrated Care Service in a real world setting deserves to be explored.

Objective: To evaluate implementation and 10 years follow-up of Home Hospitalization and Early Discharge as an Integrated Care Service in an urban healthcare district in Barcelona.

Methods: Prospective study with pragmatic assessment. Patients: Surgical and medical acute and exacerbated chronic patients requiring admission into a highly specialized hospital, from 2006 to 2015. Intervention: Home-based individualized care plan, administered as a hospital-based outreach service, aiming at substituting hospitalization and implementing a transitional care strategy for optimal discharge. Main measurements: Emergency Department, readmissions and mortality. Patients' and professionals' perspectives, technologies and costs were evaluated.

Results: 4,165 admissions (71 ± 15 yrs; Charlson Index 4 ± 3). In-hospital stay was 1 (0-3) days and the length of home-based stay was 6 (5-7) days. The 30-day readmission rate was 11% and mortality was 2%. Patients, careers and health professionals expressed high levels of satisfaction (98%). At the start, the service was reimbursed at a flat rate of 918€ per patient discharged, significantly lower than conventional hospitalization (2,879€) but still allowing the hospital to keep a balanced budget. At present, there is no difference in the payment schemes for both types of services.

Conclusions: The service freed an average of 6 in-hospital days per patient. The program showed health value generation, as well as potential for synergies with community-based Integrated Care Services.
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http://dx.doi.org/10.5334/ijic.3431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6095082PMC
May 2018

Protocol for regional implementation of collaborative self-management services to promote physical activity.

BMC Health Serv Res 2018 07 17;18(1):560. Epub 2018 Jul 17.

Respiratory Medicine Department, Hospital Clínic de Barcelona, CIBERES, Barcelona, Catalonia, Spain.

Background: Chronic diseases are generating a major health and societal burden worldwide. Healthy lifestyles, including physical activity (PA), have proven efficacy in the prevention and treatment of many chronic conditions. But, so far, national PA surveillance systems, as well as strategies for promotion of PA, have shown low impact. We hypothesize that personalized modular PA services, aligned with healthcare, addressing the needs of a broad spectrum of individual profiles may show cost-effectiveness and sustainability.

Methods: The current manuscript describes the protocol for regional implementation of collaborative self-management services to promote PA in Catalonia (7.5 M habitants) during the period 2017-2019. The protocols of three implementation studies encompassing a broad spectrum of individual needs are reported. They have a quasi-experimental design. That is, a non-randomized intervention group is compared to a control group (usual care) using propensity score methods wherein age, gender and population-based health risk assessment are main matching variables. The principal innovations of the PA program are: i) Implementation of well-structured modular interventions promoting PA; ii) Information and communication technologies (ICT) to facilitate patient accessibility, support collaborative management of individual care plans and reduce costs; and iii) Assessment strategies based on the Triple Aim approach during and beyond the program deployment.

Discussion: The manuscript reports a precise roadmap for large scale deployment of community-based ICT-supported integrated care services to promote healthy lifestyles with high potential for comparability and transferability to other sites.

Trial Registration: This study protocol has been registered at ClinicalTrials.org ( NCT02976064 ). Registered November 24th, 2016.
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http://dx.doi.org/10.1186/s12913-018-3363-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6050723PMC
July 2018

Risk and temporal order of disease diagnosis of comorbidities in patients with COPD: a population health perspective.

BMJ Open Respir Res 2018 13;5(1):e000302. Epub 2018 Jun 13.

Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.

Introduction: Comorbidities in patients with chronic obstructive pulmonary disease (COPD) generate a major burden on healthcare. Identification of cost-effective strategies aiming at preventing and enhancing management of comorbid conditions in patients with COPD requires deeper knowledge on epidemiological patterns and on shared biological pathways explaining co-occurrence of diseases.

Methods: The study assesses the co-occurrence of several chronic conditions in patients with COPD using two different datasets: Catalan Healthcare Surveillance System (CHSS) (ES, 1.4 million registries) and Medicare (USA, 13 million registries). Temporal order of disease diagnosis was analysed in the CHSS dataset.

Results: The results demonstrate higher prevalence of most of the diseases, as comorbid conditions, in elderly (>65) patients with COPD compared with non-COPD subjects, an effect observed in both CHSS and Medicare datasets. Analysis of temporal order of disease diagnosis showed that comorbid conditions in elderly patients with COPD tend to appear after the diagnosis of the obstructive disease, rather than before it.

Conclusion: The results provide a population health perspective of the comorbidity challenge in patients with COPD, indicating the increased risk of developing comorbid conditions in these patients. The research reinforces the need for novel approaches in the prevention and management of comorbidities in patients with COPD to effectively reduce the overall burden of the disease on these patients.
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http://dx.doi.org/10.1136/bmjresp-2018-000302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6018856PMC
June 2018

Population-based analysis of patients with COPD in Catalonia: a cohort study with implications for clinical management.

BMJ Open 2018 03 6;8(3):e017283. Epub 2018 Mar 6.

Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.

Background: Clinical 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.

Objective: To explore the potential of health registry information to enhance clinical risk assessment and stratification.

Design: Fixed 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.

Methods: A 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.

Results: Multimorbidity, 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.

Conclusions: The 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 Number: NCT02956395.
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http://dx.doi.org/10.1136/bmjopen-2017-017283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5855237PMC
March 2018

Network modules uncover mechanisms of skeletal muscle dysfunction in COPD patients.

J Transl Med 2018 02 20;16(1):34. Epub 2018 Feb 20.

Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.

Background: Chronic obstructive pulmonary disease (COPD) patients often show skeletal muscle dysfunction that has a prominent negative impact on prognosis. The study aims to further explore underlying mechanisms of skeletal muscle dysfunction as a characteristic systemic effect of COPD, potentially modifiable with preventive interventions (i.e. muscle training). The research analyzes network module associated pathways and evaluates the findings using independent measurements.

Methods: We characterized the transcriptionally active network modules of interacting proteins in the vastus lateralis of COPD patients (n = 15, FEV 46 ± 12% pred, age 68 ± 7 years) and healthy sedentary controls (n = 12, age 65 ± 9  years), at rest and after an 8-week endurance training program. Network modules were functionally evaluated using experimental data derived from the same study groups.

Results: At baseline, we identified four COPD specific network modules indicating abnormalities in creatinine metabolism, calcium homeostasis, oxidative stress and inflammatory responses, showing statistically significant associations with exercise capacity (VO peak, Watts peak, BODE index and blood lactate levels) (P < 0.05 each), but not with lung function (FEV). Training-induced network modules displayed marked differences between COPD and controls. Healthy subjects specific training adaptations were significantly associated with cell bioenergetics (P < 0.05) which, in turn, showed strong relationships with training-induced plasma metabolomic changes; whereas, effects of training in COPD were constrained to muscle remodeling.

Conclusion: In summary, altered muscle bioenergetics appears as the most striking finding, potentially driving other abnormal skeletal muscle responses. Trial registration The study was based on a retrospectively registered trial (May 2017), ClinicalTrials.gov identifier: NCT03169270.
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http://dx.doi.org/10.1186/s12967-018-1405-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5819708PMC
February 2018

Instrumental drift removal in GC-MS data for breath analysis: the short-term and long-term temporal validation of putative biomarkers for COPD.

J Breath Res 2018 03 14;12(3):036007. Epub 2018 Mar 14.

Signal and Information Processing for Sensing Systems, Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology, Barcelona, Spain.

Breath analysis holds the promise of a non-invasive technique for the diagnosis of diverse respiratory conditions including chronic obstructive pulmonary disease (COPD) and lung cancer. Breath contains small metabolites that may be putative biomarkers of these conditions. However, the discovery of reliable biomarkers is a considerable challenge in the presence of both clinical and instrumental confounding factors. Among the latter, instrumental time drifts are highly relevant, as since question the short and long-term validity of predictive models. In this work we present a methodology to counter instrumental drifts using information from interleaved blanks for a case study of GC-MS data from breath samples. The proposed method includes feature filtering, and additive, multiplicative and multivariate drift corrections, the latter being based on component correction. Biomarker discovery was based on genetic algorithms in a filter configuration using Fisher's ratio computed in the partial least squares-discriminant analysis subspace as a figure of merit. Using our protocol, we have been able to find nine peaks that provide a statistically significant area under the ROC curve of 0.75 for COPD discrimination. The method developed has been successfully validated using blind samples in short-term temporal validation. However, the attempt to use this model for patient screening six months later was not successful. This negative result highlights the importance of increasing validation rigor when reporting biomarker discovery results.
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http://dx.doi.org/10.1088/1752-7163/aaa492DOI Listing
March 2018

Drug-related deaths in hospital inpatients: A retrospective cohort study.

Br J Clin Pharmacol 2018 03 11;84(3):542-552. Epub 2018 Jan 11.

Department of Clinical Pharmacology, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain.

Aims: To determine the incidence of drug-related deaths (DRD) in a university hospital in 2015, to describe their characteristics, and to discover risk factors of DRD.

Methods: An analytic and retrospective cohort study. Patients with a death diagnosed predefined from a list of medical conditions potentially caused by drugs were the selected cases for further review. Causality assessment was evaluated by a local drug safety committee.

Results: Out of 1135 inpatient deaths, 73 DRD were included (six were hospital-acquired). The incidence of DRD of all hospital admissions was 0.34%, and the incidence of all deaths cases was 7%. Drugs were the cause of death in 38 patients (52%) and a contributive role in 35 (48%). The median age of DRD patients was 72 years (range 19-94) and 72.6% were men. The median hospital stay, Charlson score and number of drugs were 5 days, 2 points and seven drugs respectively. The most frequent DRD were cerebral haemorrhages and infections in drug-immunosuppressed patients (32, 43.8%, each group). The most frequently involved drugs were antineoplastics and glucocorticosteroids (40% and 18%), and antithrombotics (33%); drug-drug interactions were present in 44% DRD. Sex, age and number of drugs were risk factors of DRD.

Conclusions: Adverse drug reactions were a significant cause of death in hospitalized patients, mainly haemorrhages and infections precipitated by drug-drug interactions. Risk factors for DRD were sex, age and number of drugs. Preventable DRD and measures to avoid them should be accurately assessed in further studies.
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http://dx.doi.org/10.1111/bcp.13471DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5809345PMC
March 2018

Guidelines for Developing Successful Short Advanced Courses in Systems Medicine and Systems Biology.

Cell Syst 2017 09 23;5(3):168-175. Epub 2017 Aug 23.

Unit of Computational Medicine, Department of Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden; Center for Molecular Medicine, Karolinska Institutet, 171 77 Stockholm, Sweden; Unit of Clinical Epidemiology, Department of Medicine, Karolinska University Hospital, L8, 17176 Stockholm, Sweden; Science for Life Laboratory, 17121 Solna, Sweden; Biological and Environmental Sciences and Engineering Division (BESE), Computer, Electrical and Mathematical Sciences and Engineering Division (CEMSE), King Abdullah University of Science and Technology (KAUST), Thuwal 23955-6900, Kingdom of Saudi Arabia. Electronic address:

Systems medicine and systems biology have inherent educational challenges. These have largely been addressed either by providing new masters programs or by redesigning undergraduate programs. In contrast, short courses can respond to a different need: they can provide condensed updates for professionals across academia, the clinic, and industry. These courses have received less attention. Here, we share our experiences in developing and providing such courses to current and future leaders in systems biology and systems medicine. We present guidelines for how to reproduce our courses, and we offer suggestions for how to select students who will nurture an interdisciplinary learning environment and thrive there.
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http://dx.doi.org/10.1016/j.cels.2017.05.013DOI Listing
September 2017

Heart Rate Recovery After 6-min Walking Test Predicts Acute Exacerbation in COPD.

Lung 2017 08 17;195(4):463-467. Epub 2017 Jun 17.

Pulmonology Department (ICT), Hospital Clínic, IDIBAPS, CIBERES (ISCiii), Barcelona, Spain.

Introduction: Abnormalities of autonomic function have been reported in patients with chronic obstructive pulmonary disease (COPD). Our objectives were to identify determinants of abnormal heart rate recovery at 1 min (HRR) following completion of the 6-min walk test (6MWT) in COPD and to establish whether abnormal HRR predicts acute exacerbations (AECOPD).

Methods: Hundred one COPD patients (FEV (SD) 53 (19)  % predicted) were prospectively recruited in a multi-center study. HRR after the 6MWT was evaluated as the difference between heart rate at the end of the test and 1 min into the recovery (HRR). Linear and logistic regression was used to identify predictors of HRR and AECOPD, respectively. The best HRR cut-off point to predict AECOPD was selected using the receiver operating characteristics (ROC) curves. The follow-up period was 12 months.

Results: Distance covered during the 6MWT (m) and DLco (% predicted) were independently associated with HRR (r  = 0.51, p = 0.001). Among several potential covariates, HRR emerged as the most significant predictor of AECOPD (Odds ratio [OR], 0.91 per beat of recovery; 95% confidence interval [CI], 0.85-0.97; p = 0.02). The ROC analysis indicated that subjects with HRR less than 14 beats (AUC, 0.71 [CI] 0.60-0.80; p = 0.0001) were more likely to suffer an exacerbation during the follow-up period (for HRR, p = 0.004 [log-rank test]).

Conclusions: HRR after the 6MWT is an independent predictor factor for AECOPD. Further studies are warranted to examine the physiological mechanisms associating a delayed HRR and acute exacerbations in COPD patients.
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http://dx.doi.org/10.1007/s00408-017-0027-0DOI Listing
August 2017

Automated Spirometry Quality Assurance: Supervised Learning From Multiple Experts.

IEEE J Biomed Health Inform 2018 01 8;22(1):276-284. Epub 2017 Jun 8.

Forced spirometry testing is gradually becoming available across different healthcare tiers including primary care. It has been demonstrated in earlier work that commercially available spirometers are not fully able to assure the quality of individual spirometry manoeuvres. Thus, a need to expand the availability of high-quality spirometry assessment beyond specialist pulmonary centres has arisen. In this paper, we propose a method to select and optimise a classifier using supervised learning techniques by learning from previously classified forced spirometry tests from a group of experts. Such a method is able to take into account the shape of the curve as an expert would during visual inspection. We evaluated the final classifier on a dataset put aside for evaluation yielding an area under the receiver operating characteristic curve of 0.88 and specificities of 0.91 and 0.86 for sensitivities of 0.60 and 0.82. Furthermore, other specificities and sensitivities along the receiver operating characteristic curve were close to the level of the experts when compared against each-other, and better than an earlier rules-based method assessed on the same dataset. We foresee key benefits in raising diagnostic quality, saving time, reducing cost, and also improving remote care and monitoring services for patients with chronic respiratory diseases in the future if a clinical decision support system with the encapsulated classifier is to be integrated into the work-flow of forced spirometry testing.
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http://dx.doi.org/10.1109/JBHI.2017.2713988DOI Listing
January 2018

Personalised Prehabilitation in High-risk Patients Undergoing Elective Major Abdominal Surgery: A Randomized Blinded Controlled Trial.

Ann Surg 2018 Jan;267(1):50-56

Anesthesiology Department, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona.

Objective: The aim of this study was to assess the impact of personalized prehabilitation on postoperative complications in high-risk patients undergoing elective major abdominal surgery.

Summary Background Data: Prehabilitation, including endurance exercise training and promotion of physical activity, in patients undergoing major abdominal surgery has been postulated as an effective preventive intervention to reduce postoperative complications. However, the existing studies provide controversial results and show a clear bias toward low-risk patients.

Methods: This was a randomized blinded controlled trial. Eligible candidates accepting to participate were blindly randomized (1:1 ratio) to control (standard care) or intervention (standard care + prehabilitation) groups. Inclusion criteria were: i) age >70 years; and/or, ii) American Society of Anesthesiologists score III/IV. Prehabilitation covered 3 actions: i) motivational interview; ii) high-intensity endurance training; and promotion of physical activity. The main study outcome was the proportion of patients suffering postoperative complications. Secondary outcomes included the endurance time (ET) during cycle-ergometer exercise.

Results: We randomized 71 patients to the control arm and 73 to intervention. After excluding 19 patients because of changes in the surgical plan, 63 controls and 62 intervention patients were included in the intention-to-treat analysis. The intervention group enhanced aerobic capacity [ΔET 135 (218) %; P < 0.001), reduced the number of patients with postoperative complications by 51% (relative risk 0.5; 95% confidence interval, 0.3-0.8; P = 0.001) and the rate of complications [1.4 (1.6) and 0.5 (1.0) (P =  0.001)] as compared with controls.

Conclusion: Prehabilitation enhanced postoperative clinical outcomes in high-risk candidates for elective major abdominal surgery, which can be explained by the increased aerobic capacity.
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http://dx.doi.org/10.1097/SLA.0000000000002293DOI Listing
January 2018

From comorbidities of chronic obstructive pulmonary disease to identification of shared molecular mechanisms by data integration.

BMC Bioinformatics 2016 Nov 22;17(Suppl 15):441. Epub 2016 Nov 22.

Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain.

Background: Deep mining of healthcare data has provided maps of comorbidity relationships between diseases. In parallel, integrative multi-omics investigations have generated high-resolution molecular maps of putative relevance for understanding disease initiation and progression. Yet, it is unclear how to advance an observation of comorbidity relations (one disease to others) to a molecular understanding of the driver processes and associated biomarkers.

Results: Since Chronic Obstructive Pulmonary disease (COPD) has emerged as a central hub in temporal comorbidity networks, we developed a systematic integrative data-driven framework to identify shared disease-associated genes and pathways, as a proxy for the underlying generative mechanisms inducing comorbidity. We integrated records from approximately 13 M patients from the Medicare database with disease-gene maps that we derived from several resources including a semantic-derived knowledge-base. Using rank-based statistics we not only recovered known comorbidities but also discovered a novel association between COPD and digestive diseases. Furthermore, our analysis provides the first set of COPD co-morbidity candidate biomarkers, including IL15, TNF and JUP, and characterizes their association to aging and life-style conditions, such as smoking and physical activity.

Conclusions: The developed framework provides novel insights in COPD and especially COPD co-morbidity associated mechanisms. The methodology could be used to discover and decipher the molecular underpinning of other comorbidity relationships and furthermore, allow the identification of candidate co-morbidity biomarkers.
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http://dx.doi.org/10.1186/s12859-016-1291-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5133493PMC
November 2016

Molecular mechanisms underlying COPD-muscle dysfunction unveiled through a systems medicine approach.

Bioinformatics 2017 01 6;33(1):95-103. Epub 2016 Oct 6.

Department of Biochemistry and Molecular Biology, Faculty of Biology, Institute of Biomedicine of University of Barcelona (IBUB) and IDIBAPS, Diagonal 645, Barcelona 08028, Spain.

Motivation: Skeletal muscle dysfunction is a systemic effect in one-third of patients with chronic obstructive pulmonary disease (COPD), characterized by high reactive-oxygen-species (ROS) production and abnormal endurance training-induced adaptive changes. However, the role of ROS in COPD remains unclear, not least because of the lack of appropriate tools to study multifactorial diseases.

Results: We describe a discrete model-driven method combining mechanistic and probabilistic approaches to decipher the role of ROS on the activity state of skeletal muscle regulatory network, assessed before and after an 8-week endurance training program in COPD patients and healthy subjects. In COPD, our computational analysis indicates abnormal training-induced regulatory responses leading to defective tissue remodeling and abnormal energy metabolism. Moreover, we identified tnf, insr, inha and myc as key regulators of abnormal training-induced adaptations in COPD. The tnf-insr pair was identified as a promising target for therapeutic interventions. Our work sheds new light on skeletal muscle dysfunction in COPD, opening new avenues for cost-effective therapies. It overcomes limitations of previous computational approaches showing high potential for the study of other multi-factorial diseases such as diabetes or cancer.

Contact: jroca@clinic.ub.es or martacascante@ub.eduSupplementary information: Supplementary data are available at Bioinformatics online.
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http://dx.doi.org/10.1093/bioinformatics/btw566DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544513PMC
January 2017

Successful treatment of hepatitis C virus infection combining daclatasvir and simeprevir in a heart transplant recipient with decompensated cirrhosis.

J Heart Lung Transplant 2016 07 17;35(7):949-51. Epub 2016 May 17.

Microbiology Service, Hospital Universitari de Bellvitge, Barcelona, Spain.

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http://dx.doi.org/10.1016/j.healun.2016.05.005DOI Listing
July 2016

Protocol for regional implementation of collaborative lung function testing.

NPJ Prim Care Respir Med 2016 06 2;26:16024. Epub 2016 Jun 2.

Hospital Clinic de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain.

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http://dx.doi.org/10.1038/npjpcrm.2016.24DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4890075PMC
June 2016