Publications by authors named "Mònica Monteagudo"

22 Publications

  • Page 1 of 1

Combined Multimorbidity and Polypharmacy Patterns in the Elderly: A Cross-Sectional Study in Primary Health Care.

Int J Environ Res Public Health 2021 09 1;18(17). Epub 2021 Sep 1.

Universitat Autònoma de Barcelona, Bellaterra (Cerdanyola del Vallès), 08193 Barcelona, Spain.

(1) Background: The acquisition of multiple chronic diseases, known as multimorbidity, is common in the elderly population, and it is often treated with the simultaneous consumption of several prescription drugs, known as polypharmacy. These two concepts are inherently related and cause an undue burden on the individual. The aim of this study was to identify combined multimorbidity and polypharmacy patterns for the elderly population in Catalonia. (2) Methods: A cross-sectional study using electronic health records from 2012 was conducted. A mapping process was performed linking chronic disease categories to the drug categories indicated for their treatment. A soft clustering technique was then carried out on the final mapped categories. (3) Results: 916,619 individuals were included, with 93.1% meeting the authors' criteria for multimorbidity and 49.9% for polypharmacy. A seven-cluster solution was identified: one non-specific (Cluster 1) and six specific, corresponding to diabetes (Cluster 2), neurological and musculoskeletal, female dominant (Clusters 3 and 4) and cardiovascular, cerebrovascular and renal diseases (Clusters 5 and 6), and multi-system diseases (Cluster 7). (4) Conclusions: This study utilized a mapping process combined with a soft clustering technique to determine combined patterns of multimorbidity and polypharmacy in the elderly population, identifying overrepresentation in six of the seven clusters with chronic disease and chronic disease-drug categories. These results could be applied to clinical practice guidelines in order to better attend to patient needs. This study can serve as the foundation for future longitudinal regarding relationships between multimorbidity and polypharmacy.
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http://dx.doi.org/10.3390/ijerph18179216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8430667PMC
September 2021

Systematic review on long-term adverse effects of inhaled corticosteroids in the treatment of COPD.

Eur Respir Rev 2021 Jun 23;30(160). Epub 2021 Jun 23.

Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.

Inhaled corticosteroids (ICSs) are indicated for the prevention of exacerbations in COPD; however, a significant proportion of patients at low risk of exacerbations are treated with ICSs. We conducted a systematic review including a diversity of types of study designs and safety outcomes with the objective of describing the risk of adverse effects associated with the long-term use of ICSs in patients with COPD.A total of 90 references corresponding to 83 studies were included, including 26 randomised clinical trials (RCTs), 33 cohort studies, and 24 nested case-control (NCC) studies. Analysis of 19 RCTs showed that exposure to ICSs for ≥1 year increased the risk of pneumonia by 41% (risk ratio 1.41, 95% CI 1.23-1.61). Additionally, cohort and NCC studies showed an association between ICSs and risk of tuberculosis and mycobacterial disease. There was a strong association between ICS use and local disorders such as oral candidiasis and dysphonia. The association between ICSs and the risk of diabetes and fractures was less clear and appeared significant only at high doses of ICSs.Since most patients with COPD are elderly and with frequent comorbidities, an adequate risk-benefit balance is crucial for the indication of ICSs.
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http://dx.doi.org/10.1183/16000617.0075-2021DOI Listing
June 2021

Clinical characteristics and factors associated with triple therapy use in newly diagnosed patients with COPD.

NPJ Prim Care Respir Med 2021 03 22;31(1):16. Epub 2021 Mar 22.

Medicine Department, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.

There is limited information about the initiation of triple therapy (TT) in patients with chronic obstructive pulmonary disease (COPD) in primary care. This was an observational, population-based study in patients identified from a primary care electronic medical records database in Catalonia from 2011 to 2015 aimed to identify the use of TT in patients with newly diagnosed COPD. A total of 69,668 newly diagnosed patients were identified of whom 11,524 (16.5%) initiated TT, of whom 8626 initiated TT at or immediately after COPD diagnosis. Among them, 72.3% were GOLD A/B, 14.6% were frequent exacerbators, and 7.1% had asthma-COPD overlap (ACO). Variables associated with TT initiation were: male sex, older age, previous exacerbations, ACO, a previous treatment regimen containing an inhaled corticosteroid, previous pneumonia, and history of lung cancer. A significant number of COPD patients in Primary Care initiated TT shortly after or even before an established COPD diagnosis.
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http://dx.doi.org/10.1038/s41533-021-00227-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985144PMC
March 2021

Treatment Pathways Before and After Triple Therapy in COPD: A Population-based Study in Primary Care in Spain.

Arch Bronconeumol (Engl Ed) 2021 Mar 29;57(3):205-213. Epub 2020 Sep 29.

Pneumology Department, Hospital Universitari Vall d́Hebron, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus. CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain; Medicine Department, Autonomous University of Barcelona (UAB), Bellaterra (Cerdanyola del Vallés), Barcelona, Spain. Electronic address:

Background: Recent data from real world clinical practices on the use of Triple Therapy (TT) in patients with COPD are scarce.

Methods: Observational population-based study with longitudinal follow-up in patients with COPD identified in a primary care electronic medical records database in Catalonia, covering 80% of the general population. The aims were to characterize COPD patients who initiated TT and to describe treatment pathways before and after TT initiation. Time to and probability of step down or complete discontinuation of TT was described using restricted mean survival time and Kaplan-Meier analysis.

Results: A total of 34,018 COPD patients initiated TT during the study period. Of them, 23,867 (70.1%) were GOLD A/B. 18,453 (54.2%) were non-exacerbators, 9931 (29.2%) infrequent exacerbators, 5634 (16.5%) frequent exacerbators and 1923 (5.6%) had asthma-COPD overlap. Drugs most frequently used prior to initiation of TT were long-acting antimuscarinics (22.5%) and combination of long-acting beta2 agonists/inhaled corticosteroids (15.2%). A total of 11,666 (34.3%) stepped down and 1091 (3.2%) discontinued TT during follow-up. Step down following TT was more likely in patients with severe COPD, especially during the first year; however, discontinuation was more common among patients with mild COPD.

Conclusion: Most patients initiating treatment with TT were non exacerbators and continued on the same treatment over time regardless severity of disease. Stepping down was more frequent in severe patients, while discontinuation was more common among mild patients. Overall, it appears that TT is extensively used in primary care for treatment of patients with COPD.
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http://dx.doi.org/10.1016/j.arbres.2020.07.032DOI Listing
March 2021

Blood Eosinophil Counts and Their Variability and Risk of Exacerbations in COPD: A Population-Based Study.

Arch Bronconeumol (Engl Ed) 2021 Jan 13;57(1):13-20. Epub 2020 Feb 13.

Ciber de Enfermedades Respiratorias (CIBERES), Spain; Respiratory Department, Hospital de Alta Resolución de Loja, Granada, Spain.

Background: There is controversy regarding the role of blood eosinophil levels as a biomarker of exacerbation risk in chronic obstructive pulmonary disease (COPD). Our aim was to quantify blood eosinophil levels and determine the risk of exacerbations associated with these levels and their variability.

Methods: Observational, retrospective, population-based study with longitudinal follow-up in patients with COPD identified in a primary care electronic medical record database in Catalonia, Spain, covering 80% of the general population. Patients were classified into 4 groups using the following cut-offs: (a) <150cells/μl; (b) ≥150 and <300cells/μl; (c) ≥300 and <500cells/μl; (d) ≥500cells/μl.

Results: A total of 57,209 patients were identified with a mean age of 70.2 years, a mean FEV1(% predicted) of 64.1% and 51.6% had at least one exacerbation the previous year. The number of exacerbations in the previous year was higher in patients with the lowest and the highest eosinophil levels compared with the intermediate groups. During follow-up the number of exacerbations was slightly higher in the group with the lowest blood eosinophil levels and in those with higher variability in eosinophil counts, but ROC curves did not identify a reliable threshold of blood eosinophilia to discriminate an increased risk of exacerbations.

Conclusions: Our results do not support the use of blood eosinophil count as a reliable biomarker of the risk of exacerbation in COPD in a predominantly non-exacerbating population. Of note was that the small group of patients with the highest variability in blood eosinophils more frequently presented exacerbations.
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http://dx.doi.org/10.1016/j.arbres.2019.12.015DOI Listing
January 2021

Population-based study of LAMA monotherapy effectiveness compared with LABA/LAMA as initial treatment for COPD in primary care.

NPJ Prim Care Respir Med 2018 09 28;28(1):36. Epub 2018 Sep 28.

Pneumology Department, Hospital Universitari Vall d´Hebron. Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.

This epidemiological study aimed to describe and compare the characteristics and outcomes of COPD patients starting treatment with a long-acting anti-muscarinic (LAMA) or a combination of a long-acting beta-2 agonist (LABA)/LAMA in primary care in Catalonia (Spain) over a one-year period. Data were obtained from the Information System for the Development in Research in Primary Care (SIDIAP), a population database containing information of 5.8 million inhabitants (80% of the population of Catalonia). Patients initiating treatment with a LAMA or LABA/LAMA in 2015 were identified, and information about demographic and clinical characteristics was collected. Then, patients were matched 1:1 for age, sex, FEV1%, history of exacerbations, history of asthma and duration of treatment, and the outcomes between the two groups were compared. During 2015, 5729 individuals with COPD started treatment with a LAMA (69.8%) or LAMA/LABA (30.2%). There were no remarkable differences between groups except for a lower FEV1 and more previous hospital admissions in individuals on LABA/LAMA. The number of tests and referrals was low and decreased in both groups during follow-up. For the same severity status, the evolution was similar with a reduction in exacerbations in both groups. Treatment was changed during follow-up in up to 34.2% of patients in the LABA/LAMA and 26.3% in the LAMA group, but adherence was equally good for both. Our results suggest that initial therapy with LAMA in monotherapy may be adequate in a significant group of mild to moderate patients with COPD and a low risk of exacerbations managed in primary care.
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http://dx.doi.org/10.1038/s41533-018-0102-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6162319PMC
September 2018

Long-term efficacy and effectiveness of a behavioural and community-based exercise intervention (Urban Training) to increase physical activity in patients with COPD: a randomised controlled trial.

Eur Respir J 2018 10 18;52(4). Epub 2018 Oct 18.

ISGlobal, Barcelona, Spain.

There is a need to increase and maintain physical activity in patients with chronic obstructive pulmonary disease (COPD). We assessed 12-month efficacy and effectiveness of the Urban Training intervention on physical activity in COPD patients.This randomised controlled trial (NCT01897298) allocated 407 COPD patients from primary and hospital settings 1:1 to usual care (n=205) or Urban Training (n=202). Urban Training consisted of a baseline motivational interview, advice to walk on urban trails designed for COPD patients in outdoor public spaces and other optional components for feedback, motivation, information and support (pedometer, calendar, physical activity brochure, website, phone text messages, walking groups and a phone number). The primary outcome was 12-month change in steps·day measured by accelerometer.Efficacy analysis (with per-protocol analysis set, n=233 classified as adherent to the assigned intervention) showed adjusted (95% CI) 12-month difference +957 (184-1731) steps·day between Urban Training and usual care. Effectiveness analysis (with intention-to-treat analysis set, n=280 patients completing the study at 12 months including unwilling and self-reported non-adherent patients) showed no differences between groups. Leg muscle pain during walks was more frequently reported in Urban Training than usual care, without differences in any of the other adverse events.Urban Training, combining behavioural strategies with unsupervised outdoor walking, was efficacious in increasing physical activity after 12 months in COPD patients, with few safety concerns. However, it was ineffective in the full population including unwilling and self-reported non-adherent patients.
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http://dx.doi.org/10.1183/13993003.00063-2018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6203405PMC
October 2018

Child and Adolescent Sexual Abuse in Women Seeking Help for Sexual and Reproductive Mental Health Problems: Prevalence, Characteristics, and Disclosure.

J Child Sex Abus 2017 Apr;26(3):246-269

a Programmes for Sexual and Reproductive Care of Catalonia , Catalan Health Institute , Barcelona , Spain.

This is a multicentric, descriptive, cross-sectional study of child and adolescent sexual abuse in women over 18 years in 24 primary care sexual and reproductive health centers in Catalonia. A total of 1,013 women were recruited; 345 (37.6%, 95% CI: 34.6-40.9) reported exposure to child sexual abuse: 32.4% disclosed being touched in a sexual way, and 9.6% reported completed sexual intercourse. Abuse occured before the age of 13 in 63.4% of respondents. The perpetrator was a relative or an acquaintance in almost 80% of cases. The risk was higher among women of Central or South American origin (OR: 2.86; 95% CI: 1.33-6.12). Only 31.9% of women disclosed the abuse and 17.3% were blamed. Abuse that involved attempted or completed sexual intercourse was significantly associated with recurrence, physical violence, and revictimization in adulthood.
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http://dx.doi.org/10.1080/10538712.2017.1288186DOI Listing
April 2017

Characteristics of COPD patients initiating treatment with aclidinium or tiotropium in primary care in Catalonia: a population-based study.

Int J Chron Obstruct Pulmon Dis 2017 12;12:1145-1152. Epub 2017 Apr 12.

Pneumology Department, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain.

Objective: To describe and compare demographic and clinical profile of patients newly initiated on aclidinium (ACL) or tiotropium (TIO) and identify factors associated with newly initiated ACL in real-life clinical practice during 2013 in Catalonia.

Design: We performed a population-based, retrospective, observational study with data obtained from the Information System for Research Development in Primary Care, a population database that contains information of 5.8 million inhabitants (more than 80% of the Catalan population). Patients over 40 years old, with a recorded diagnosis of COPD and newly initiated treatment with either ACL or TIO during the study period (January to December 2013), were selected. A descriptive analysis of demographic and clinical characteristics was performed, and treatment adherence was also assessed for both cohorts.

Results: A total of 8,863 individuals were identified, 4,293 initiated with ACL and 4,570 with TIO. They had a mean age of 69.4 years (standard deviation: 11.3), a median COPD duration of 3 years (interquartile range: 0-8), and 71% were males. Patients treated with ACL were older, with more respiratory comorbidities, a longer time since COPD diagnosis, worse forced expiratory volume in 1 second (% predicted), and with a higher rate of exacerbations during the previous year compared with TIO. It was found that 41.3% of patients with ACL and 62.3% of patients with TIO had no previous COPD treatment. Inhaled corticosteroid and long-acting β2-agonist were the most frequent concomitant medications (32.9% and 32.6%, respectively). Approximately 75% of patients were persistent with ACL or TIO at 3 months from the beginning of treatment, and more than 50% of patients remained persistent at 9 months.

Conclusion: Patients initiated with ACL had more severe COPD and were taking more concomitant respiratory medications than patients initiated with TIO. ACL was more frequently initiated as part of triple therapy, while TIO was more frequently initiated as monotherapy.
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http://dx.doi.org/10.2147/COPD.S131016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5396831PMC
March 2018

Socio-environmental correlates of physical activity in patients with chronic obstructive pulmonary disease (COPD).

Thorax 2017 09 1;72(9):796-802. Epub 2017 Mar 1.

Barcelona Institute of Global Health (ISGlobal), Barcelona, Spain.

Background: Study of the causes of the reduced levels of physical activity in patients with COPD has been scarce and limited to biological factors.

Aim: To assess the relationship between novel socio-environmental factors, namely dog walking, grandparenting, neighbourhood deprivation, residential surrounding greenness and residential proximity to green or blue spaces, and amount and intensity of physical activity in COPD patients.

Methods: This cross-sectional study recruited 410 COPD patients from five Catalan municipalities. Dog walking and grandparenting were assessed by questionnaire. Neighbourhood deprivation was assessed using the census Urban Vulnerability Index, residential surrounding greenness by the satellite-derived Normalized Difference Vegetation Index, and residential proximity to green or blue spaces as living within 300 m of such a space. Physical activity was measured during 1 week by accelerometer to assess time spent on moderate-to-vigorous physical activity (MVPA) and vector magnitude units (VMU) per minute.

Findings: Patients were 85% male, had a mean (SD) age of 69 (9) years, and post-bronchodilator FEV of 56 (17) %pred. After adjusting for age, sex, socio-economic status, dyspnoea, exercise capacity and anxiety in a linear regression model, both dog walking and grandparenting were significantly associated with an increase both in time in MVPA (18 min/day (p<0.01) and 9 min/day (p<0.05), respectively) and in physical activity intensity (76 VMU/min (p=0.05) and 59 VMUs/min (p<0.05), respectively). Neighbourhood deprivation, surrounding greenness and proximity to green or blue spaces were not associated with physical activity.

Conclusions: Dog walking and grandparenting are associated with a higher amount and intensity of physical activity in COPD patients.

Trial Registration Number: Pre-results, NCT01897298.
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http://dx.doi.org/10.1136/thoraxjnl-2016-209209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5738536PMC
September 2017

Prevalence and incidence of bronchiectasis in Catalonia, Spain: A population-based study.

Respir Med 2016 12 25;121:26-31. Epub 2016 Oct 25.

Pneumology Department, Hospital Universitari Vall d'Hebron, CIBER de Enfermedades Respiratorias (CIBERES), Barcelona, Spain. Electronic address:

Background: Insufficient epidemiological data are available on bronchiectasis in southern European populations. The aim of this study was to determine the prevalence and incidence of bronchiectasis in Catalonia, Spain and describe the characteristics of patients with an active diagnosis of bronchiectasis in 2012.

Methods: This study used data from a population database containing information from 5.8 million people (80% of the population of Catalonia). Patients with bronchiectasis were identified using International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) codes, and information on clinical characteristics and treatment was extracted.

Results: A total of 20895 patients with bronchiectasis were identified in 2012. The prevalence of bronchiectasis was 36.2 cases per 10 000 inhabitants, with an incidence of 4.81 cases per 10 000 inhabitants. Prevalence and incidence increased with age and were highest in men over 65 years of age. Among the whole bronchiectasis population in Primary Care, 48.6% of patients had had blood tests, 11.2% had undergone spirometry, only 2.1% had a chest X-ray, and 0.9% had undergone high-resolution computed tomography or sputum culture. 56% had at least one exacerbation and 12.5% had been admitted to hospital during the year of the study. The drugs most frequently used were inhaled corticosteroids (in 37.4% of patients) and long-acting βagonists (in 36%); half of the patients received no treatment (51.8%).

Conclusions: The prevalence and incidence of bronchiectasis increases with age. The management of bronchiectasis in primary care was not optimal, and the disease continues to represent an important clinical burden.
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http://dx.doi.org/10.1016/j.rmed.2016.10.014DOI Listing
December 2016

[Impact of childhood sexual abuse on the sexual and affective relationships of adult women].

Gac Sanit 2017 May - Jun;31(3):210-219. Epub 2016 Sep 15.

Programa d'Atenció a la Salut Sexual i Reproductiva (PASSIR) de Catalunya, Generalitat de Catalunya, Barcelona, España; Institut Català de la Salut, Barcelona, España; Consorci Parc de Salut Mar, Barcelona, España.

Objective: To analyse perceived sexual satisfaction, sexual dysfunction, satisfaction with affective relationships and confidence and communication in existing relationships, related to a past history of childhood sexual abuse (CSA) and type suffered, among women treated as part of the Catalonian Sexual and Reproductive Health Care Programme (PASSIR).

Method: Multicentric, descriptive, cross-sectional study. A total of 1,013 women over the age of 18 years, who underwent psychological therapy at any of the 24 PASSIR centres, were enrolled. A structured, anonymised, self-administered Sex History Questionnaire adapted from Wyatt (1985) & Dubé et al. (2005), and the Female Sexual Function Index (Rosen, 2000), were used. Statistical analysis was descriptive, bivariate and multivariate.

Results: Women who suffered childhood sexual abuse had a significantly higher prevalence of sexual dysfunction, with lower perceived sexual satisfaction. CSA with penetration or attempted penetration was associated with greater arousal difficulties and greater rejection. Women who experienced CSA were less confident and experienced greater communication difficulties with their partner.

Conclusions: It is necessary to identify potential childhood sexual abuse among women who seek therapy due to relationship problems. It is also necessary to continue research into protective factors and therapeutic interventions to alleviate the consequences of CSA in adult life.
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http://dx.doi.org/10.1016/j.gaceta.2016.05.010DOI Listing
April 2018

Diagnosis of alpha-1 antitrypsin deficiency: a population-based study.

Int J Chron Obstruct Pulmon Dis 2016 10;11:999-1004. Epub 2016 May 10.

Department of Pneumology, Vall d';Hebron University Hospital, Barcelona, Spain; Medicine Department, Autonomous University of Barcelona (UAB), Barcelona, Spain; CIBER of Respiratory Diseases (CIBERES), Spain.

Introduction: Alpha-1 antitrypsin deficiency (AATD) remains an underdiagnosed condition despite initiatives developed to increase awareness. The objective was to describe the current situation of the diagnosis of AATD in primary care (PC) in Catalonia, Spain.

Methods: We performed a population-based study with data from the Information System for Development in Research in Primary Care, a population database that contains information of 5.8 million inhabitants (80% of the population of Catalonia). We collected the number of alpha-1 antitrypsin (AAT) determinations performed in the PC in two periods (2007-2008 and 2010-2011) and described the characteristics of the individuals tested.

Results: A total of 12,409 AAT determinations were performed (5,559 in 2007-2008 and 6,850 in 2010-2011), with 10.7% of them in children. As a possible indication for AAT determination, 28.9% adults and 29.4% children had a previous diagnosis of a disease related to AATD; transaminase levels were above normal in 17.7% of children and 47.1% of adults. In total, 663 (5.3%) individuals had intermediate AATD (50-100 mg/dL), 24 (0.2%) individuals had a severe deficiency (<50 mg/dL), with a prevalence of 0.19 cases of severe deficiency per 100 determinations. Nine (41%) of the adults with severe deficiency had a previous diagnosis of COPD/emphysema, and four (16.7%) were diagnosed with COPD within 6 months.

Conclusion: The number of AAT determinations in the PC is low in relation to the prevalence of COPD but increased slightly along the study period. The indication to perform the test is not always clear, and patients detected with deficiency are not always referred to a specialist.
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http://dx.doi.org/10.2147/COPD.S108505DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4869627PMC
January 2017

Treatment patterns in COPD patients newly diagnosed in primary care. A population-based study.

Respir Med 2016 Feb 23;111:47-53. Epub 2015 Dec 23.

Pneumology Department, Hospital General Universitari Vall d'Hebron, Ciber de Enfermedades Respiratorias (CIBERES), Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain. Electronic address:

Introduction: Treatment for COPD is tailored based on clinical characteristics and severity. However, prescription patterns in COPD patients newly diagnosed in primary care may differ from guideline recommendations.

Method: We performed an epidemiological study with data obtained from the Information System for the Development in Research in Primary Care (SIDIAP), a population database that contains information of 5.8 million inhabitants (80% of the population of Catalonia). Patients newly diagnosed with COPD from 2007 to 2012 were identified and information about the initial treatment patterns was collected. The initial treatment was also described by phenotype and severity.

Results: During the study period 41,492 patients were newly diagnosed with COPD. Patients were classified as non exacerbators (28,552 patients, 69%), asthma-COPD overlap syndrome (ACOS) (2152 patients, 5.2%) and frequent exacerbators (10,888 patients, 27.6%). Among the patients in whom FEV1 was available, 13.9% were GOLD stage 1, 55.2% stage 2, 26% stage 3 and 4.8% stage 4. Globally, the most frequently prescribed treatment patterns were short-acting bronchodilators (SABD) in monotherapy (17.7%), long-acting β-2 agonists (LABA) + inhaled corticosteroids (ICS) (17.3%) and triple therapy (12.2%). The frequency of patients treated with a SABD increased from 15.9% to 19.5% during the study period, while the number of untreated patients decreased from 24.4% to 15.1%. Up to 45.2% of patients were initially treated with ICS, which were frequently prescribed in the ACOS (69.2%) and in the exacerbator phenotype patients (52.4%) while ICS use has decreased from 43.8% in 2007 to 35.8% in 2012 in non exacerbator patients. Up to 13.6% and 14.8% of GOLD 4 patients received no treatment or only SABD after diagnosis.

Conclusions: Initial treatment patterns in newly diagnosed COPD patients often do no comply with guidelines. The use of ICS is excessive but has decreased mainly in non exacerbator patients. Many COPD patients still remain untreated after diagnosis, although this has decreased. Some GOLD 4 patients are still receiving SABD or no treatment at all after diagnosis.
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http://dx.doi.org/10.1016/j.rmed.2015.12.004DOI Listing
February 2016

Effectiveness of an intervention designed to optimize statins use: a primary prevention randomized clinical trial.

BMC Fam Pract 2014 Jul 15;15:135. Epub 2014 Jul 15.

Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.

Background: Although hypercholesterolemia is considered a cardiovascular risk factor, in isolation it is not necessarily sufficient cause for a cardiovascular event. To improve event prediction, cardiovascular risk calculators have been developed; the REGICOR calculator has been validated for use in our population. The objective of this project is to develop an intervention with general practitioners (GPs) and evaluate its impact on prescription adequacy of cholesterol-lowering drugs in primary prevention of cardiovascular disease and in controlling the costs associated with this disease.

Methods: This nonblinded, cluster-randomized clinical trial analyzes data from primary care electronic medical records (ECAP) and other databases. Inclusion criteria are patients aged 35 to 74 years with no known cardiovascular disease and a new prescription for cholesterol-lowering drugs during the 2-year study period. Dependent variables include the following: RETIRA, defined as new cholesterol-lowering drugs initiated during the year preceding the intervention, considered inadequate, and withdrawn during the study period; EVITA, defined as new cholesterol-lowering drugs initiated during the study period and considered inadequate; COST, defined as the total cost of inadequate new treatments prescribed; and REGISTER, defined as the recording of cardiovascular risk factors. Independent variables include the GP's quality-of-care indicators and randomly assigned study group (intervention vs control), patient demographics, and clinical variables. Aggregated descriptive analysis will be done at the GP level and multilevel analysis will be performed to estimate the intervention effect, adjusted for individual and GP variables.

Discussion: The study objective is to generate evidence about the effectiveness of implementing feedback information programs directed to GPs in the context of Primary Care. The goal is to improve the prescription adequacy of lipid-lowering therapies for primary prevention.

Trial Registration: ClinicalTrials.gov Identifier: NCT01997671. November 28, 2013.
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http://dx.doi.org/10.1186/1471-2296-15-135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4112648PMC
July 2014

Factors associated with changes in quality of life of COPD patients: a prospective study in primary care.

Respir Med 2013 Oct 17;107(10):1589-97. Epub 2013 Jun 17.

Research Department, IDIAP Jordi Gol, Barcelona, Spain; PhD Program in Public Health and Methodology of Biomedical Research, Universitat Autònoma de Barcelona, Spain. Electronic address:

Background: A primary objective in the treatment of patients with chronic obstructive pulmonary disease (COPD) is to improve their health status.

Objective: To identify the factors associated with changes in health-related quality of life (HRQoL) in patients with COPD after one year of follow-up in primary care.

Method: Multicenter, prospective study with one year of follow-up. The end-point was the change in total score on the Saint George's Respiratory Questionnaire (SGRQ). Patients with a clinically relevant (>4 points) decrease or increase in SGRQ total score were compared. Factors associated with the changes in HRQoL observed after one year were determined by logistic regression analysis.

Results: A total of 791 patients (mean age, 70.2 years) were analyzed. Mean FEV1 (% predicted) was 52.4%. Average total SGQR score was 37.1 (SD = 19.1) at baseline and 35.6 (SD = 18.9) at follow-up. Significantly improved HRQoL was observed in 36.7% of patients, and was associated with starting polymedication, pulmonology visits, and balanced diet; ending respiratory rehabilitation, quitting smoking; and not being a frequent exacerbator. Quality of life worsened significantly in 29.2% of patients, and was associated with worsening respiratory symptoms and increased hospital admissions.

Conclusions: Although overall changes in HRQoL observed after one year were minimal, more than one third of patients improved significantly, and one third had significantly worse HRQoL. Clinical factors were independently associated with these changes, emphasizing the relevance to improved HRQoL of starting a healthy lifestyle and respiratory treatments and the negative impact on HRQoL of COPD symptoms onset and admissions.
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http://dx.doi.org/10.1016/j.rmed.2013.05.009DOI Listing
October 2013

Effect of health professional education on outcomes of chronic obstructive pulmonary disease in primary care: a non-randomized clinical trial.

Respirology 2013 May;18(4):718-27

Research Department, IDIAP Jordi Gol, Barcelona, Spain.

Background And Objective: The best strategy to achieve optimal integrated management to patients with chronic obstructive pulmonary disease (COPD) in primary care (PC) is not clear. We aimed to evaluate the effectiveness of an intervention in PC based on an integrated programme, which combines diverse strategies directed at health professionals to improve quality of life and clinical outcomes of their patients with COPD. We compared the outcome with results from standard practice.

Methods: A prospective, multicentre, quasi-experimental study and a 12-month follow up was performed. Intervention consisted of an integrated education programme in PC. The main outcome variable was the change in total score of the St. George's Respiratory Questionnaire (SGRQ) at the end of follow up between the control and intervention group.

Results: A total of 801 patients participated in the study with a mean age of 70.2 years and a mean FEV1 (% predicted) of 55%. At 1-year follow up, the SGRQ score did not significantly differ. Although the intervention group showed an improvement in dietary, exercise and smoking habits, there was an increase in reported exacerbations and hospital admissions (P < 0.001).

Conclusions: Implementation of an integrated education programme in a PC setting, which combines diverse strategies directed at health professionals, did not achieve the expected changes in quality of life measured by SGRQ at 1-year follow up. Nonetheless, this study observed an improvement in patients' lifestyle choices, even though this did not result in a significant change in the clinical evolution or heath status over 12 months.
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http://dx.doi.org/10.1111/resp.12074DOI Listing
May 2013

Gender differences in negative mood states in secondary school students: health survey in Catalonia (Spain).

Gac Sanit 2013 Jan-Feb;27(1):32-9. Epub 2012 Mar 29.

Institut d'Investigació en Atenció Primària Jordi Gol, Barcelona, Spain.

Objective: To determine the prevalence of negative mood states in adolescents according to gender, to analyze variability among schools, and to evaluate the associated factors.

Methods: A cross-sectional study with a cluster design was carried out. We administered the High-school students health survey to a sample of 9,340 students (aged 14-16 years) in the third and fourth year of Compulsory Secondary Education in Catalonia, Spain, during the 2005-6 academic year. The main outcome measure was evidence of a negative mood state. A multilevel logistic regression model stratified by gender was used to identify the factors associated with negative mood states and to determine variability among distinct schools.

Results: Approximately 19% of adolescents reported evidence of a negative mood state, with a higher prevalence in girls (25%). The most significant factors associated with negative mood states were "use of tranquilizers" and "having eating disorders" in girls and "not exercising" and "poor self-perception of health status" in boys. In both genders, variability was found among schools in the prevalence of negative mood states (girls: variance = 0.078; p <0.001; boys: variance = 0.079; p = 0.012).

Conclusions: The prevalence of negative mood states in adolescent boys and girls was high. Differences were observed between genders in the factors related to these health states. The variability observed in the prevalence of negative mood states among distinct schools could not be explained by the study variables. Our results emphasize the association between the use of tranquilizers and negative mood states.
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http://dx.doi.org/10.1016/j.gaceta.2012.01.009DOI Listing
January 2014

Gender differences in sexual risk behaviour among adolescents in Catalonia, Spain.

Gac Sanit 2011 Jan-Feb;25(1):13-9

IDIAP Jordi Gol, Barcelona, Spain.

Objective: To analyze the factors associated with sexual risk behavior in adolescent girls and boys in order to plan future school health interventions.

Methods: A cross-sectional study with two-stage cluster sampling that included 97 schools and 9,340 students aged between 14 and 16 years old was carried out in 2005-2006 in Catalonia (Spain). For the survey, a self-administered paper-based questionnaire was used. The questionnaire contained items on sociodemographic variables, use of addictive substances and mood states, among other items. These variables were tested as risk factors for unsafe sexual behavior.

Results: This study included 4,653 boys and 4,687 girls with a mean age of 15 years. A total of 38.7% of students had had sexual relations at least once and 82.3% of boys and 63.0% of girls were engaged in sexual risk behaviors. The prevalence of sexual relations and risk behaviors was generally higher in boys than in girls, independently of the variables analyzed. Boys had more sexual partners (P<.001) and used condoms as a contraceptive method less frequently than girls (P<.001). Foreign origin was related to unsafe sexual activity in both genders. Alcohol consumption was also a risk factor in boys.

Conclusions: Sexual risk behaviors among adolescents in Catalonia are higher in boys than in girls. Factors related to unsafe sexual activity in boys were foreign origin and alcohol consumption. In girls only foreign origin was a significant risk factor.
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http://dx.doi.org/10.1016/j.gaceta.2010.07.012DOI Listing
July 2011

Variability in the performing of spirometry and its consequences in the treatment of COPD in primary care.

Arch Bronconeumol 2011 May 4;47(5):226-33. Epub 2011 Feb 4.

Área científica IDIAP Jordi Gol, Barcelona, España.

Background: Several studies have approached the use of spirometry in the treatment of chronic obstructive pulmonary disease (COPD) in Primary Care (PC), but few have analysed its impact on the treatment of the patient with COPD.

Objectives: To evaluate the use of spirometry in the diagnosis and follow-up of COPD patients in PC, and its impact on treatment. To analyse the variation in the performing of spirometry between PC centres.

Methodology: A multicentre, observational and cross-sectional study of COPD patients seen in PC in Catalonia (Spain) during 2004-2005. A multilevel logistic regression model was used to identify factors associated with having spirometry and to determine the variation between the different centres.

Results: Twenty-one centres which included 801 patients took part. Only 53.2% of them had a diagnostic spirometer available and the mean (standard deviation) FEV1(%) was 54.8% (18%). The registers of smoking habits, complementary tests and spirometry follow-up were more common among patients who had a diagnostic spirometry available compared to those who did not. No statistically significant differences were found as regards demographic, clinical, treatment and quality of life variables between patients with and without follow-up spirometry. Significant variation was observed in the percentage of diagnostic spirometries between different PC centres (variance=0.217; p<0.001).

Conclusion: Spirometry is underused in PC and performing it during follow-up is not associated to the different treatments received, or with a more complete approach to the disease. There is significant variation in the performing of spirometry among PC centres.
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http://dx.doi.org/10.1016/j.arbres.2010.10.009DOI Listing
May 2011

Evaluation of a combined strategy directed towards health-care professionals and patients with chronic obstructive pulmonary disease (COPD): information and health education feedback for improving clinical monitoring and quality-of-life.

BMC Public Health 2009 Dec 1;9:442. Epub 2009 Dec 1.

Unit Methodology, Assessment and Quality, SAP Dreta, Catalan Health Institute, 08025 Barcelona, Spain.

Background: Chronic obstructive pulmonary disease (COPD) is a health problem that is becoming increasingly attended-to in Primary Care (PC). However, there is a scarcity of health-care programs and studies exploring the implementation of Clinical Practice Guidelines (CPG). The principal objective of the present study is to evaluate the effectiveness of a combined strategy directed towards health-care professionals and patients to improve the grade of clinical control and the quality-of-life (QoL) of the patients via a feedback on their state-of-health. A training plan for the health-care professionals is based on CPG and health education.

Method/design: Multi-centred, before-after, quasi experimental, prospective study involving an intervention group and a control group of individuals followed-up for 12 months. The patients receive attention from urban and semi-urban Primary Care Centres (PCC) within the administrative area of the Costa de Ponent (near Barcelona). All the pacients corresponding to the PCC of one sub-area were assigned to the intervention group and patients from the rest of sub-areas to the group control. The intervention includes providing data to the health-care professionals (clinician/nurse) derived from a clinical history and an interview. A course of training focused on aspects of CPG, motivational interview and health education (tobacco, inhalers, diet, physical exercise, physiotherapy). The sample random includes a total of 801 patients (> or = 40 years of age), recorded as having COPD, receiving attention in the PCC or at home, who have had at least one clinical visit, and who provided written informed consent to participation in the study. Data collected include socio-demographic characteristics, drug treatment, exacerbations and hospital admissions, evaluation of inhaler use, tobacco consumption and life-style and health-care resources consumed. The main endpoints are dyspnoea, according to the modified scale of the Medical Research Council (MRC) and the QoL, evaluated with the St George's Respiratory Questionnaire (SGRQ). The variables are obtained at the start and the end of the intervention. Information from follow-up visits focuses on the changes in life-style activities of the patient.

Discussion: This study is conducted with the objective of generating evidence that shows that implementation of awareness programs directed towards health-care professionals as well as patients in the context of PC can produce an increase in the QoL and a decrease in the disease exacerbation, compared to standard clinical practice.

Trial Registration: Clinical Trials.gov Identifier: NCT00922545;
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http://dx.doi.org/10.1186/1471-2458-9-442DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2799410PMC
December 2009

Incidence and risk factors of exacerbations among COPD patients in primary health care: APMPOC study.

BMC Public Health 2009 Jan 9;9. Epub 2009 Jan 9.

Primary Healthcare Research Support Unit Barcelonès Nord i Maresme, IDIAP Jordi Gol, Mataró, Spain.

Background: Worldwide, chronic obstructive pulmonary disease (COPD) is the fourth cause of death. Exacerbations have a negative impact on the prognosis of COPD and the frequency and severity of these episodes are associated with a higher patient mortality. Exacerbations are the first cause of decompensation, hospital admission and death in COPD. The incidence of exacerbations has mainly been estimated in populations of patients with moderate-severe COPD requiring hospital care. However, little is known regarding the epidemiology of exacerbations in patients with less severe COPD forms. It is therefore possible that a high number of these less severe forms of exacerbations are underdiagnosed and may, in the long-term, have certain prognostic importance for the COPD evolution. The aim of this study was to know the incidence and risk factors associated with exacerbations in patients with COPD in primary care.

Methods And Design: A prospective, observational, 3-phase, multicentre study will be performed involving: baseline evaluation, follow up and final evaluation. A total of 685 smokers or ex-smokers from 40 to 80 years of age with COPD, without acute respiratory disease or any other long-term respiratory disease will be randomly selected among the population assigned to 21 primary care centres. The diagnosis of COPD and its severity will be confirmed by spirometry. Information regarding the baseline situation, quality of life and exposure to contaminants or other factors potentially related to exacerbations will be collected. A group of 354 patients with confirmed COPD of varying severity will be followed for one year through monthly telephone calls and daily reporting of symptoms with the aim of detecting all the exacerbations which occur. These patients will be evaluated again at the end of the study and the incidence of exacerbations and associated relative risks will be estimated by negative binomial regression.

Discussion: The results will be relevant to provide knowledge about natural history of the initial phases of the COPD and the impact and incidence of the exacerbations on the patients with mild-moderate forms of the disease. These data may be important to know the milder forms of exacerbation which are often silent or very little expressed clinically.
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http://dx.doi.org/10.1186/1471-2458-9-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2633267PMC
January 2009
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