Methodological guidelines for preparing a structured therapeutic education program: From design to evaluation

BACKGROUND AND OBJECTIVE

Therapeutic patient education (TPE) is effective and essential in the context of the growing prevalence of chronic diseases, in which tools are needed for planning structured programs. The objective of this project was to develop guidelines for designing and assessing a TPE program.

METHODS

1) We assembled a multidisciplinary group of 8 leaders in TPE, chronicity, quality and safety from the hospital and the university. 2) We conducted an exhaustive review of the scientific literature on the planning of TPE programs directed at chronically ill patients, their relatives and caregivers. 3) The final text underwent comments and suggestions by participants from the hospital and primary care centre during a course on information and TPE methodology. The recommendations were unanimously agreed upon by the writing group.

RESULTS

We obtained a standardised work procedure targeted at professionals involved in planning TPE programs, based on international recommendations. The document is structured into sections: a) Definition of the health problem and analysis of the situation; b) Program structure (human resources and materials); objectives (health-related, behaviour-related and educational) and methodology; c) Path the patient and family/caregiver follows in the program; and d) Assessment and indicators. The assessment of the procedure, in the framework of the methodology courses, was favourable.

CONCLUSIONS

The methodology provided by this document serves as an instrument for the standardised and systematic planning of educational programs and unifies the criteria in their drafting. However, the document needs to be adapted to the condition and population to which each program is directed.

Analysis of the quality of patient therapeutic education and information in a high complexity reference hospital

BACKGROUND AND OBJECTIVES

The application and monitoring of quality criteria in information and therapeutic patient education can identify areas to improve care. The objectives of this study were: (1) To analyze the characteristics of patient information materials, educational activities, and self-management programs, and (2) to determine health care provider (HCP) proposals on therapeutic patient education.

MATERIALS AND METHODS

Using a cross-sectional study, an online questionnaire was sent to hospital departments in a high complexity reference hospital from September to December 2013 to record: (a) information materials, (b) patient educational activities, and self-management program characteristics, (c) HCP proposals. The materials were analyzed using Health Promoting Hospitals (HPH) recommendations.

RESULTS

(1) An analysis was performed on 258 materials (leaflets [54%]) for chronic patients (86%), acute patients (7%), and the general population (7%). More than half (55%) lacked the authors, and 43% the year issued, and 69% followed HPH recommendations. (2) An evaluation was made of 70 educational activities and 37 self-management programs addressed to patients/relatives with diabetes/obesity, musculoskeletal disorders, COPD/asthma, pelvic-floor disorders, transplantation, bowel-inflammation/liver disease, hypertension, cancer, heart failure, acquired immune deficiency syndrome, chronic renal insufficiency, splenectomy, anticoagulation and older-patient dependence. The structure, process and outcome evaluation varied. (3) HCP proposals included: standardization of materials criteria, web accessibility, list of accredited websites, cross-sectional use, and HCP training in self-management education.

CONCLUSIONS

The online questionnaire showed the weaknesses and strengths of patient information and education, and can be used to monitor their quantity and quality. These results help in the definition of a useful model to improve patient information and education policies.

Spanish and Catalan translation, cultural adaptation and validation of the Picker Patient Experience Questionnaire-15

OBJECTIVE

To develop and test a culturally adapted core set of questions to measure patients' experience after in-patient care.

MATERIAL AND METHODS

Following the methodology recommended by international guides, a basic set of patient experience questions, selected from Picker Institute Europe questionnaires (originally in English), was translated to Spanish and Catalan. Acceptability, construct validity and reliability of the adapted questionnaire were assessed via a cross-sectional validation study. The inclusion criteria were patients aged >18 years, discharged within one week to one month prior to questionnaire sending and whose email was available. Day cases, emergency department patients and deaths were excluded. Invitations were sent by email (N=876) and questionnaire was fulfilled through an online platform. An automatic reminder was sent 5 days later to non-respondents.

RESULTS

A questionnaire, in Spanish and Catalan, with adequate conceptual and linguistic equivalence was obtained. Response rate was 44.4% (389 responses). The correlation matrix was factorable. Four factors were extracted with Parallel Analysis, which explained 43% of the total variance. First factor: information and communication received during discharge. Second factor: low sensitivity attitudes of professionals. Third factor: assessment of communication of medical and nursing staff. Fourth factor: global items. The value of the Cronbach alpha was 0.84, showing a high internal consistency.

CONCLUSIONS

The obtained experience patient questionnaire, in Spanish and Catalan, shows good results in the psychometric properties evaluated and could be a useful tool to identify opportunities for health care improvement in our context. Email could become a feasible tool for greater patient participation in everything that concerns his health.

Discharge planning and home care for end-stage COPD patients

Discharge support for the most seriously ill chronic obstructive pulmonary disease (COPD) patients is a key issue in minimising the impact of the acute episode and preventing future relapses. Alternatives to hospitalisation are crucial in the cost minimisation of COPD care. However, besides efficiency, there are clinical reasons for promoting alternatives to conventional hospital admission. Hospital stay itself conveys a risk to patients. The discharge process is a key element in the healthcare continuum. Hospital at home is a safe alternative to hospital admission, but it is not the only means of supporting discharge. Some home care schedules, mainly supported by nurses, have been proven to be good alternatives. Home care is also useful in the prevention of hospital admission. Integrated care is a comprehensive response to the needs of severely affected COPD patients achieved through models of shared care utilising all relevant health providers and promoting self-management. The framework for integrated care is the so-called chronic care model, centred on the promotion of self-management, the holistic appraisal of the patient, the most appropriate design of healthcare delivery responding effectively to the needs of the patient and a good system of shared and accessible information.

Home mechanical ventilation patients: a retrospective survey to identify level of burden in real life

BACKGROUND AND AIM

Home care for patients under home mechanical ventilation (HMV) may cause dramatic physical and economic burden in addition to the burden of time on family/caregivers and health care service (HCS) with difficult resource allocation decision-making. Our aims were: 1. To identify conditions causing major care burden in managing HMV patients according to family and payer's perspectives related to characteristics of the disease, dependency and accessibility; and 2. To find, if any, differences among diseases.

METHODS

A questionnaire was sent to eight pulmonary centres to identify factors connected with the greater care burden. Retrospective data of 792 patients still alive and in HMV was reviewed.

RESULTS

Compared to neuromuscular disorders (NM) and chest wall deformities, the COPD group have presented a statistically greater number of hospitalisations/yr (1.37 +/- 0.77), greater length of stay (13 +/- 10 days), higher number of outpatient visits/yr (2.55 +/- 1.73) or emergency room accesses/yr (0.74 +/- 1.08). Patients with NM diseases need more home care. The prevalence of one, two and three among five selected burden criteria (needs of MV > 12 hrs/day, tracheotomy, high dependency, distance from hospital, frequent hospitalisations) was respectively 19%, 30% and 33% of the cases; the NM was the group most represented.

CONCLUSIONS

In HMV patients: 1. underlying disease, level of their dependency, hours spent under MV, presence of tracheotomy, home distance from hospital, hospital accesses are the causes of major care burden; and 2. as a novelty we have demonstrated that more than fifty percent of them present two or three contemporaneous criteria selected as care burden, being NM and COPD patients the most representative group necessitating of family's and HCS's care respectively.

Noninvasive positive pressure ventilation prevents postoperative pulmonary complications in chronic ventilators users

OBJECTIVE

To evaluate the postoperative pulmonary complications and the long-term impact on pulmonary function of different surgical procedures with general anaesthesia in chronic respiratory failure (CRF) patients who were using noninvasive positive pressure ventilation (NPPV).

DESIGN

We retrospectively studied 20 stable patients on NPPV for CRF secondary to: kyphoscoliosis (eight), morbid obesity (six), thoracoplasty (four), neuromuscular diseases (two), who underwent surgical procedures with general anaesthesia, between January 1998 and December 2003.

MATERIAL AND METHODS

The variables studied were: type of surgery, hours of orotracheal intubation, hours of stay in the postsurgical reanimation unit (PRU), postoperative pulmonary complications and days of hospital stay. These results were compared with those obtained in patients without respiratory pathology and who were submitted to the same type of surgical interventions during the study period. All patients were tested for: arterial blood gases, forced vital capacity (FVC) and forced expiratory volume in 1s (FVE1). These tests were carried out both prior to surgical intervention and 12 months after this intervention, and the use of medical assistance resources the year prior to and the year after the surgical intervention were also analysed.

RESULTS

Sixteen patients were using NPPV at home at the time of the intervention and four patients were adapted to NPPV before surgery. The surgical procedures were: gastroplasty: six; mastectomy: five; septoplasty: three; hip prosthesis: two; cholecystectomy: one; Gasserian ganglion thermocoagulation: one; hysterectomy: one; and endoscopic retrograde cholangiopancreatography (ERCP): one. The mean postoperative intubation time was 3.8+/-3.2h, and only one patient remained intubated for more than 12h. The mean stay in the PRU was 19+/-9h (vs 19+/-6h in the general population, p>0.05). The days of hospital stay for the different pathologies were in the majority of cases greater than in the general population. We did not find significant differences on comparing the arterial blood gases, in pulmonary function or in use of assistance resources between the year previous to and the year following the surgical intervention.

CONCLUSIONS

In high-risk patients with chronic respiratory failure as a consequence of a restrictive lung pathology, NPPV can play an important role to confront surgical procedure with general anaesthesia with greater security. To obtain these results, it was fundamental to coordinate between the Pulmonary Services and the Anaesthesia Services as well as to follow up jointly in the PRU.

Performance of mechanical ventilators at the patient's home: a multicentre quality control study

BACKGROUND

Quality control procedures vary considerably among the providers of equipment for home mechanical ventilation (HMV).

METHODS

A multicentre quality control survey of HMV was performed at the home of 300 patients included in the HMV programmes of four hospitals in Barcelona. It consisted of three steps: (1) the prescribed ventilation settings, the actual settings in the ventilator control panel, and the actual performance of the ventilator measured at home were compared; (2) the different ventilator alarms were tested; and (3) the effect of differences between the prescribed settings and the actual performance of the ventilator on non-programmed readmissions of the patient was determined.

RESULTS

Considerable differences were found between actual, set, and prescribed values of ventilator variables; these differences were similar in volume and pressure preset ventilators. The percentage of patients with a discrepancy between the prescribed and actual measured main ventilator variable (minute ventilation or inspiratory pressure) of more than 20% and 30% was 13% and 4%, respectively. The number of ventilators with built in alarms for power off, disconnection, or obstruction was 225, 280 and 157, respectively. These alarms did not work in two (0.9%), 52 (18.6%) and eight (5.1%) ventilators, respectively. The number of non-programmed hospital readmissions in the year before the study did not correlate with the index of ventilator error.

CONCLUSIONS

This study illustrates the current limitations of the quality control of HMV and suggests that improvements should be made to ensure adequate ventilator settings and correct ventilator performance and ventilator alarm operation.

Quality control of equipment in home mechanical ventilation: a European survey

Quality control of the equipment used in home mechanical ventilation is necessary in order to ensure that patients safely and accurately receive the prescribed ventilatory support. The aim of this study was to carry out a survey on the quality-control procedures in different centres and countries. The survey was carried out in the context of a European Commission Concerted Action covering 16 European countries. The study was extensive and detailed, involving 326 centres, which provided home ventilation to >20,000 patients. The survey showed that: 1) ventilator servicing was mainly carried out by external companies (62% of centres), with a servicing frequency ranging 3-12 months; 2) interaction between servicing companies and prescribers was limited (only 61% of centres were always informed of major incidents); 3) participation of centres in equipment quality control was poor (only 56% of centres assessed that patients/caregivers correctly cleaned/maintained the ventilator); and 4) centres were insufficiently aware of vigilance systems (only 23% of centres). Moreover, the data showed considerable inter- and intra-country differences. The size of the centre was an important determinant of many of these quality-control aspects. This survey provides information that will enable the European Commission Concerted Action to formulate recommendations on procedures for home-ventilator quality control.

Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients

It was postulated that home hospitalisation (HH) of selected chronic obstructive pulmonary disease (COPD) exacerbations admitted at the emergency room (ER) could facilitate a better outcome than conventional hospitalisation. To this end, 222 COPD patients (3.2% female; 71+/-10 yrs (mean+/-SD)) were randomly assigned to HH (n=121) or conventional care (n=101). During HH, integrated care was delivered by a specialised nurse with the patient's free-phone access to the nurse ensured for an 8-week follow-up period. Mortality (HH: 4.1%; controls: 6.9%) and hospital readmissions (HH: 0.24+/-0.57 controls: 0.38+/-0.70) were similar in both groups. However, at the end of the follow-up period, HH patients showed: 1) a lower rate of ER visits (0.13+/-0.43 versus 0.31+/-0.62); and 2) a noticeable improvement of quality of life (delta St George's Respiratory Questionnaire (SGRQ), -6.9 versus -2.4). Furthermore, a higher percentage of patients had a better knowledge of the disease (58% versus 27%), a better self-management of their condition (81% versus 48%), and the patient's satisfaction was greater. The average overall direct cost per HH patient was 62% of the costs of conventional care, essentially due to fewer days of inpatient hospitalisation (1.7+/-2.3 versus 4.2+/-4.1 days). A comprehensive home care intervention in selected chronic obstructive pulmonary disease exacerbations appears as cost effective. The home hospitalisation intervention generates better outcomes at lower costs than conventional care.

Sexuality in chronic respiratory failure: coincidences and divergences between patient and primary caregiver

Sexual functioning can be affected by chronic illness in a variety of ways. These problems affect the patients relationship and the degree of satisfaction with his partner. We conducted a study in order to evaluate the perception of sexual difficulties and changes in communication with patients and their wives. Male chronic obstructive pulmonary disease patients with (COPD) and chronic respiratory failure on long-term oxygen therapy were studied. The evaluation method used has consisted of the individualized administration of a semi-structured interview created for this purpose. This interview was conducted with the patients and their wives. One part of the interview was dedicated to evaluating possible sexual problems and how these problems affect the relationship between the couples. In addition, patients as well as their partners were asked the degree of satisfaction with their partners and the degree of satisfaction with their lives. Forty-nine patients and their spouses have been included in the study. Thirty-three patients (67.3%) showed some type of sexual problem (lack of desire and/or impotence). Sixteen wives (33%) answered affirmatively to the question about whether changes at a communicative level as a consequence of the patients illness had occurred. In relation to the appearance of sexual changes, 46 (94%) of the wives answered affirmatively. The wives were significantly less satisfied with the relationship than the patients, which was related to communication problems. The group of patients were more satisfied with their partners than with their life, whereas no difference has been observed in the wives with both variables. An important percentage of patients with chronic insufficiency who have sexual difficulties exits. A factor which influences the perception of such problems in a very important way is the degree of affection in the relationship between the couples.

Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation. EFRAM study

Although exacerbation of chronic obstructive pulmonary disease (COPD) is important in terms of health and costs, there is little information about which are the risk factors. We estimated the association between modifiable and nonmodifiable potential risk factors of exacerbation and the admission for a COPD exacerbation, using a case-control approach. Cases were recruited among admissions for COPD exacerbation during 1 yr in four tertiary hospitals of the Barcelona area. Control subjects were recruited from hospital's register of discharges, having coincided with the referent case in a previous COPD admission but being clinically stable when the referent case was hospitalized. All patients completed a questionnaire and performed spirometry, blood gases, and physical examination. Information about potential risk factors was collected, including variables related to clinical status, characteristics of medical care, medical prescriptions, adherence to medication, lifestyle, quality of life, and social support. A total of 86 cases and 86 control subjects were included, mean age 69 yr, mean FEV(1) 39% of predicted. Multivariate logistic regression showed the following risk (or protective) factors of COPD hospitalization: three or more COPD admissions in the previous year (odds ratio [OR] 6.21, p = 0.008); FEV(1) (OR 0.96 per percentual unit, p < 0.0005); underprescription of long-term oxygen therapy (LTOT) (OR 22.64, p = 0.007); and current smoking (OR 0.30, p = 0.022). Among a wide range of potential risk factors we have found that only previous admissions, lower FEV(1), and underprescription of LTOT are independently associated with a higher risk of admission for a COPD exacerbation.

Impact of a resident strike on emergency department quality indicators at an urban teaching hospital

OBJECTIVE

To evaluate the indicators of activity and quality within the emergency department (ED) during a resident physicians' strike.

METHODS

This was an observational study comparing a strike period (SP) and a non-strike period (NSP) in the ED of a 1,000-bed tertiary care teaching hospital in Barcelona, Spain, with an annual census of 100,000 emergency visits. During a period of nine nonconsecutive days, the resident physicians were on strike. Emergency visits were handled by staff members. Data were compared between all patients treated in the ED during the SP and those treated during the NSP, matched by the weekday. The authors compared lengths of stay (LOSs), rates of use of laboratory tests and radiology procedures, numbers of patient walkouts, patient/physician ratios, emergency hospital admission rates, home discharge rates, unscheduled return rates, and mortality rates.

RESULTS

The two groups (SP 2,610 patients and NSP 3,634 patients) were comparable in terms of average daily attendance rate (SP: 290 +/- 12 vs NSP: 302 +/- 21; p = 0.13), elective hospital admission rate, and severity of illness. Statistically significant differences were found in terms of mean total patients' LOS (SP: 206.75 +/- 12.27 vs NSP: 235.10 +/- 27.08 minutes; p < 0.001), number of laboratory tests per patient (SP: 0.30 +/- 0.05 vs NSP: 0.38 +/- 0.04; p < 0.001), and radiographs per patient (SP: 0.78 +/- 0.06 vs NSP: 0.88 +/- 0.09; p = 0.021).

CONCLUSIONS

This study demonstrated that replacing residents with staff physicians resulted in fewer laboratory tests ordered, fewer radiographs ordered, and shorter lengths of stays in the ED.

Impact of a hospital-based home-care program on the management of COPD patients receiving long-term oxygen therapy

STUDY OBJECTIVES

To analyze the influence of a hospital-based home-care program (HCP) on the management of patients with COPD receiving long-term oxygen therapy.

DESIGN AND SETTING

Randomized, controlled study in a 1,000-bed university hospital.

INTERVENTION

The HCP applied to patients in the intervention group (HCP group) consisted of a monthly telephone call, home visits every 3 months, and home or hospital visits on a demand basis. Patients in the control group were given conventional medical care.

MEASUREMENTS

Pulmonary function data, gas exchange, use of hospital resources (emergency department visits, admissions, and hospital stay) and the cost of medical assistance were investigated in both groups before and after 1 year of study. Quality of life was analyzed using the chronic respiratory questionnaire in the first 40 consecutive patients included in the study. Survival throughout the study was also assessed.

RESULTS

One hundred twenty-two patients were enrolled in the study, and 94 patients (46 in the HCP group and 48 in the control group) completed the 1-year follow-up period: 83 patients (88%) were men, and mean (+/- SD) age was 68 +/- 8 years. During the follow-up period, there was a highly significant decrease in the mean number of emergency department visits (0.45 +/- 0.83 vs 1.58 +/- 1.96; p = 0.0001) and also a significant decrease in hospital admissions (0.5 +/- 0.86 vs 1.29 +/- 1.7; p = 0.001) and days of hospital stay (7.43 +/- 15.6 vs 18.2 +/- 24.5; p = 0.01) in the HCP group. Patients in the intervention group required a total of 221 home visits (mean per patient, 4.8 +/- 0.8) and 69 hospital visits (mean per patient, 1.5 +/- 1.07). In spite of the cost of the program, cost analysis showed a total saving of 8.1 million pesetas ($46,823) in the HCP group, mainly due to a decrease in the use of hospital resources. There was no difference in pulmonary function, gas exchange, quality of life, and survival between the two groups.

CONCLUSIONS

Hospital-based home care is an effective alternative to hospital admission. It reduces the use of hospital resources and the cost of health care.

[Usefulness of home visits in the control and evaluation of the appropriate use of home continuous oxygen therapy]

The aim of this study was to determine the usefulness of home visits to monitor and evaluate the appropriate use of domiciliary oxygen therapy (DOT). Appropriateness was based on the coincidence of circumstances needed to predict benefit from DOT: appropriate indications correct hypoxemia and patient compliance. All patients receiving DOT residing in the town of L'Hospitalet (Barcelona) in June 1994 were enrolled. During a home visit to each patient a questionnaire was administered and spirometric variables, CO in exhaled air and pulse oximetry were recorded. If DOT was not considered appropriate, the patient was referred to the hospital clinic for reevaluation of the prescription. One hundred twenty-eight patients (74% men) were visited. Mean age was 68 years. Use of DOT was seen to be appropriate in only 26% of patients. The prescription of DOT was considered strictly correct in 73 patients (49%); 13 of them were seen to have continued smoking. Of the 60 remaining patients, hypoxemia was correct with oxygen therapy in 46, and of these only 33 complied with DOT. The home visit combined with hospital monitoring allowed us to withdraw DOT from 20 patients, for whom the indications had been incorrect, and to introduce changes in oxygen supply sources for 16 patients who carried pumps. Fourteen started using a concentrator and 2 began using liquid oxygen. Periodic review is necessary for optimal treatment of DOT. The home visit is a good tool for improving DOT follow-up, as it allows the patient to be assessed in the setting where DOT is really applied. It is a monitoring method that is well accepted by the patient.

Transtracheal catheter acceptance and adverse events in long-term home oxygen therapy

The acceptance of transtracheal catheters (TTC) in chronic obstructive pulmonary disease (COPD) patients with severe hypoxaemia was analysed and the adverse events associated with this system of oxygenation described. Once the TTC (Oxycat) was inserted, each patient was monitored on an outpatient basis and information about the associated adverse events was collected. In a group of 70 patients that met the inclusion criteria, only 14 (20%) accepted TTC insertion. The observed adverse events were: haemorrhage through the stoma (3); ejection of the TTC in a cough reflex (2); subcutaneous emphysema (2); mucous plugging (1); and haemoptysis (1). Removal of the TTC was necessary in 29% of the cases, and was associated with the onset of an adverse event in all cases except one. Despite the proven benefits of oxygen therapy performance and the improvement in effort tolerance, transtracheal catheter has a low level of acceptance among patients with extremely disabling diseases. The adverse events observed were frequent, but could have been corrected and in no case worsened our patients' prognosis.

Long-term mechanical ventilation in amyotrophic lateral sclerosis

BACKGROUND

Acute respiratory insufficiency (ARI) with alveolar hypoventilation or incapacitating dyspnoea but without peripheral muscle involvement can be an early manifestation of respiratory involvement in amyotrophic lateral sclerosis (ALS). Some of these patients benefit from assisted ventilation. The object of this study was to analyse the results of long-term mechanical ventilation (LTMV) in ten patients with ALS.

METHODS

A retrospective analysis of intensive care unit (ICU) or ambulant patients with ALS who underwent LTMV in a conventional hospital ward was performed. Erect and supine spirometry, blood gas analysis and pulse oximetry were performed before the start and during the course of ventilation.

RESULTS

Ten patients on LTMV were included. Four from the ICU were ventilated via tracheostomy, and six ambulant patients had non-invasive (nasal) ventilation. In all cases, ventilation was performed in a conventional hospital ward. The ambulant patients improved symptomatically during ventilation, confirmed by measurement of gas exchange and of SaO2 by continuous pulse oximetry. Three of the ten patients survive in long-term care--two with nasal and one with tracheostomy ventilation.

CONCLUSIONS

LTMV outside ICU was possible in ten patients, seven of whom returned home. Returning home is very difficult for patients dependent on a ventilator who lack family support.

The importance of process variables analysis in the assessment of long-term oxygen therapy by concentrator

The aim of the present study was to evaluate process variables and intermediate outcomes involved in long-term oxygen therapy (LTOT) by concentrator with the purpose of identifying which of those factors would be the most influential in the final health outcome of the therapy. A cross-sectional survey was carried out on a random sample of 111 patients receiving LTOT by concentrator in Catalonia (Spain). Patients were interviewed and assessed at home by a trained physician, and the variables collected were arterial oxygen saturation, performance of the concentrators, and patient compliance. Sixty-two patients participated in the study. Overall, LTOT was appropriately prescribed in 36 patients, of whom only 29 were able to correct their level of hypoxaemia. Patient compliance with treatment was considered adequate in 19 of those 29 patients. Thus, only 19 of 62 patients (31%) fulfilled those criteria needed to achieve the expected clinical benefits. Strategies for improving the effectiveness of medical interventions or technologies ought to consider those factors of the therapeutic process which might influence the expected health outcomes in a specific health-care context.

[Appropriate use and effectiveness of chronic domiciliary oxygen therapy in Catalonia]

BACKGROUND

The aim of this study was to study the pattern of the use of chronic domiciliary oxigenotherapy (CDO) in Catalonia, Spain.

METHODS

A transversal study including 110 patients randomly selected from a list of all the subjects with CDO (n = 3,585) was made. A domiciliary survey on the characteristics of the indication for CDO and its fulfillment was carried out. Two pulsioximetries were also performed one breathing room air and another with oxigen.

RESULTS

Of the 70 eligible patients the following factors were simultaneously observed in only 14 (20% of the total): adequate indication for CDO, use of oxigen at a flow which corrected the hypoxemia, and prescription fulfillment. The most important cause of inadequate usage of CDO was inappropriate indication since only 19 patients (27%) presented SaO2 less than or equal to 88%. Hypoxemia was not corrected in four of these 19 patients. Thirty-seven percent of the total admitted bad fulfillment, bot only one of the 15 patients with SaO2 less than or equal to 88% and in whom hypoxemia was corrected, recognized bad fulfillment. Sixty-nine percent of the patients had a document explaining the way and length of time they should receive the oxigen.

CONCLUSIONS

The inappropriate indication of CDO is the main factor influencing the low effectiveness of chronic domiciliary oxigenotherapy in Catalonia.

Complex decisions about an uncomplicated therapy: reimbursement for long-term oxygen therapy in Catalonia (Spain)

Therapies used in the management of chronic diseases cause specific problems regarding reimbursement policy. Oxygen therapy is an example of such treatments that receive little attention from health care policy makers, due to their low cost to the health care budget and to their little importance from a social point of view. In this paper, we analyze the problems posed by this therapy in the Catalan health care system, as an example of the several aspects implied in the reimbursement of such kind of therapies. A technology assessment of this therapy was carried out showing that a change in the reimbursement of long-term home oxygen therapy (LTOT) was needed. Slow diffusion of new oxygen delivery modalities and over-prescription of LTOT were among the problems observed. The new system proposed is presented, and some preliminary results and consequences of the role of technology assessment in health care policy-making are discussed.

[Effectiveness of the concentrator as a supply source in home oxygen therapy]

The oxygen concentrator is an effective supply source in home oxygen-therapy (HO). In order to study the effectivity of the concentrator in HO, we visited at home 31 patients using the concentrator as the only oxygen supply source in the exit gas and counted the hours of concentrator usage. Only 13 concentrators (41.9%) supplied a percentage of oxygen higher than 87% at a flow of two liters per minute. In three cases (9.7%), sporadic control measures of the percentage of oxygen in the exit gas were being taken and only four patients (12.9%) said that these controls were made monthly. The concentrator did not supply the adequate percentage of oxygen in 12 out of the 29 patients correctly taking the HO, so the effectivity of the treatment can only be expected in 28.6% of studied cases. The concentrator operates well under ideal conditions, but potential breakdowns in standard conditions of use must be considered. The efficiency of the HO with concentrator in our environment is very low, but it can be improved with regular controls of the concentrators or the introduction of devices warning the patient when they detect a reduction of the percentage of oxygen in the exit gas.

[The evaluation of the oxygen-conserving valve during exertion]

BACKGROUND

The oxygen-conserving valve (OCV) permits reduction in oxygen consumption upon the release of oxygen only during inhalation thereby increasing the autonomy of portable sources.

METHODS

In order to confirm its efficacy during exercise, 15 patients with chronic limitation of air flow and gasometric criteria of domiciliary oxygen therapy were selected. The patients underwent three walking tests (WT) of 6 minutes during which the continuous form of transcutaneous hemoglobin saturation (SaO2) and the distance covered were registered. The first was carried out breathing synthetic air at a flow of 2 liters per minute; the second with continuous oxygen released by a portable source at 2 liters per minute and the third with the OCV coupled to a portable source at the same flow.

RESULTS

SaO2 reached with the continuous oxygen is significantly higher to that of synthetic air while there was no difference between the SaO2 with continuous oxygen and with valve. Improvement in SaO2 upon use the valve was not obtained in only 2 of the 15 patients. A significant increase was observed in the distance covered upon oxygen administration not only in the continuous form but also with OCV with respect to synthetic air.

CONCLUSIONS

OCV is as effective as continuous oxygen in the correction of desaturation during exercise, however its indications must be individualized by exercise tests (WT) in each patients in order to ensure its correct functioning.

[Long-term effects of home mechanical ventilation with positive pressure using a nasal mask]

Home mechanical ventilation (HMV) is an efficient alternative in the treatment of patients with chronic respiratory failure secondary to restrictive mechanical disorders (neuromuscular disease, such as Duchenne's disease, thorax deformities due to kyphoscoliosis or tuberculosis sequelae). The case of a patient with severe kyphoscoliosis in the phase of chronic respiratory failure (PaO2 34 mmHg and PaCO2 61 mmHg, breathing ambient air) is presented in which, following the failure of negative pressure mechanical ventilation ("poncho"), positive pressure ventilation was tested with a silicon made-to-measure nasal mask as the access via. Adaptation to HMV was good with the patient using the ventilation nightly. Following 12 months of treatment the patient is able to carry out everyday activities and arterial gasometry breathing ambient air is PaO2 77 mmHg and PaCO2 43 mmHg.

[The introduction of liquid oxygen as a portable source in continuous home oxygen therapy]

The most widespread types of oxygen delivery at home in our area are bottles where the gas is stored under pressure and concentrators. Both devices can only be used at rest. We have assessed a new system for the delivery of liquid oxygen to be used at home, provided with a portable unit which permits that the patients receive oxygen also outside their homes. Seven such devices have been implemented in the Barcelona area, with an excellent acceptance and without technical problems. To verify the clinical indication, exercise tests were carried out both in baseline conditions and receiving oxygen from the portable source. Oxyhemoglobin saturation and the walked distance were continuously measured. In all patients important drops in the saturation of oxyhemoglobin were recorded during walking, which was corrected with oxygen administration. Liquid oxygen with a portable source is a good delivery system for oxygen therapy at home, permitting to receive oxygen throughout the day, particularly during exercise. Although the availability of liquid oxygen is limited, it should be recommended to the patients in whom exercise hypoxemia is shown to be corrected and who desire an active social life.