The value of admission avoidance: cost-consequence analysis of one-year activity in a consolidated service

BACKGROUND

Many advantages of hospital at home (HaH), as a modality of acute care, have been highlighted, but controversies exist regarding the cost-benefit trade-offs. The objective is to assess health outcomes and analytical costs of hospital avoidance (HaH-HA) in a consolidated service with over ten years of delivery of HaH in Barcelona (Spain).

METHODS

A retrospective cost-consequence analysis of all first episodes of HaH-HA, directly admitted from the emergency room (ER) in 2017-2018, was carried out with a health system perspective. HaH-HA was compared with a propensity-score-matched group of contemporary patients admitted to conventional hospitalization (Controls). Mortality, re-admissions, ER visits, and direct healthcare costs were evaluated.

RESULTS

HaH-HA and Controls (n = 441 each) were comparable in terms of age (73 [SD16] vs. 74 [SD16]), gender (male, 57% vs. 59%), multimorbidity, healthcare expenditure during the previous year, case mix index of the acute episode, and main diagnosis at discharge. HaH-HA presented lower mortality during the episode (0 vs. 19 (4.3%); p < 0.001). At 30 days post-discharge, HaH-HA and Controls showed similar re-admission rates; however, ER visits were lower in HaH-HA than in Controls (28 (6.3%) vs. 34 (8.1%); p = 0.044). Average costs per patient during the episode were lower in the HaH-HA group (€ 1,078) than in Controls (€ 2,171). Likewise, healthcare costs within the 30 days post-discharge were also lower in HaH-Ha than in Controls (p < 0.001).

CONCLUSIONS

The study showed higher performance and cost reductions of HaH-HA in a real-world setting. The identification of sources of savings facilitates scaling of hospital avoidance.

REGISTRATION

ClinicalTrials.gov (26/04/2017; NCT03130283).

Aerobic capacity and mitochondrial function in bipolar disorder: a longitudinal study during acute phases and after clinical remission

Background

Aerobic capacity has shown to predict physical and mental health-related quality of life in bipolar disorder (BD). However, the correlation between exercise respiratory capacity and mitochondrial function remains understudied. We aimed to assess longitudinally intra-individual differences in these factors during mood episodes and remission in BD.

Methods

This study included eight BD patients admitted to an acute psychiatric unit. Incremental cardiopulmonary exercise test (CPET) was conducted during acute episodes (T0), followed by constant work rate cycle ergometry (CWRCE) to evaluate endurance time, oxygen uptake at peak exercise (VO2peak) and at the anaerobic threshold. The second test was repeated during remission (T1). Mitochondrial respiration rates were assessed at T0 and T1 in peripheral blood mononuclear cells.

Results

Endurance time, VO2peak, and anaerobic threshold oxygen consumption showed no significant variations between T0 and T1. Basal oxygen consumption at T1 tended to inversely correlate with maximal mitochondrial respiratory capacity (r=-0.690, p=0.058), and VO2peak during exercise at T1 inversely correlated with basal and minimum mitochondrial respiration (r=-0.810, p=0.015; r=-0.786, p=0.021, respectively).

Conclusions

Our preliminary data showed that lower basal oxygen consumption may be linked to greater mitochondrial respiratory capacity, and maximum oxygen uptake during the exercise task was associated with lower basal mitochondrial respiration, suggesting that lower oxygen requirements could be associated with greater mitochondrial capacity. These findings should be replicated in larger samples stratified for manic and depressive states.

Five years of Hospital at Home adoption in Catalonia: impact, challenges, and proposals for quality assurance

BACKGROUND

Hospital at home (HaH) was increasingly implemented in Catalonia (7.7 M citizens, Spain) achieving regional adoption within the 2011-2015 Health Plan. This study aimed to assess population-wide HaH outcomes over five years (2015-2019) in a consolidated regional program and provide context-independent recommendations for continuous quality improvement of the service.

METHODS

A mixed-methods approach was adopted, combining population-based retrospective analyses of registry information with qualitative research. HaH (admission avoidance modality) was compared with a conventional hospitalization group using propensity score matching techniques. We evaluated the 12-month period before the admission, the hospitalization, and use of healthcare resources at 30 days after discharge. A panel of experts discussed the results and provided recommendations for monitoring HaH services.

RESULTS

The adoption of HaH steadily increased from 5,185 episodes/year in 2015 to 8,086 episodes/year in 2019 (total episodes 31,901; mean age 73 (SD 17) years; 79% high-risk patients. Mortality rates were similar between HaH and conventional hospitalization within the episode [76 (0.31%) vs. 112 (0.45%)] and at 30-days after discharge [973(3.94%) vs. 1112(3.24%)]. Likewise, the rates of hospital re-admissions at 30 days after discharge were also similar between groups: 2,00 (8.08%) vs. 1,63 (6.58%)] or ER visits [4,11 (16.62%) vs. 3,97 (16.03%). The 27 hospitals assessed showed high variability in patients' age, multimorbidity, severity of episodes, recurrences, and length of stay of HaH episodes. Recommendations aiming at enhancing service delivery were produced.

CONCLUSIONS

Besides confirming safety and value generation of HaH for selected patients, we found that this service is delivered in a case-mix of different scenarios, encouraging hospital-profiled monitoring of the service.

Reduced mitochondrial respiratory capacity in patients with acute episodes of bipolar disorder: Could bipolar disorder be a state-dependent mitochondrial disease?

BACKGROUND

Bipolar disorder (BD) is a chronic and recurrent disease characterized by acute mood episodes and periods of euthymia. The available literature postulates that a biphasic dysregulation of mitochondrial bioenergetics might underpin the neurobiology of BD. However, most studies focused on inter-subject differences rather than intra-subject variations between different mood states. To test this hypothesis, in this preliminary proof-of-concept study, we measured in vivo mitochondrial respiration in patients with BD during a mood episode and investigated differences compared to healthy controls (HC) and to the same patients upon clinical remission.

METHODS

This longitudinal study recruited 20 patients with BD admitted to our acute psychiatric ward with a manic (n = 15) or depressive (n = 5) episode, and 10 matched HC. We assessed manic and depressive symptoms using standardized psychometric scales. Different mitochondrial oxygen consumption rates (OCRs: Routine, Leak, electron transport chain [ETC], Rox) were assessed during the acute episode (T0) and after clinical remission (T1) using high-resolution respirometry at 37°C by polarographic oxygen sensors in a two-chamber Oxygraph-2k system in one million of peripheral blood mononuclear cells (PMBC). Specific OCRs were expressed as mean ± SD in picomoles of oxygen per million cells. Significant results were adjusted for age, sex, and body mass index.

RESULTS

The longitudinal analysis showed a significant increase in the maximal oxygen consumption capacity (ETC) in clinical remission (25.7 ± 16.7) compared to the acute episodes (19.1 ± 11.8, p = 0.025), and was observed separately for patients admitted with a manic episode (29.2 ± 18.9 in T1, 22.3 ± 11.9 in T0, p = 0.076), and at a trend-level for patients admitted with a depressive episode (15.4 ± 3.9 in T1 compared to 9.4 ± 3.2 in T0, p = 0.107). Compared to HC, significant differences were observed in ETC in patients with a bipolar mood episode (H = 11.7; p = 0.003). Individuals with bipolar depression showed lower ETC than those with a manic episode (t = -3.7, p = 0.001). Also, significant differences were observed in ETC rates between HC and bipolar depression (Z = 1.000, p = 0.005).

CONCLUSIONS

Bioenergetic and mitochondrial dysregulation could be present in both manic and depressive phases in BD and, importantly, they may restore after clinical remission. These preliminary results suggest that mitochondrial respiratory capacity could be a biomarker of illness activity and clinical response in BD. Further studies with larger samples and similar approaches are needed to confirm these results and identify potential biomarkers in different phases of the disease.

A Practice-Proven Adaptive Case Management Approach for Innovative Health Care Services (Health Circuit): Cluster Randomized Clinical Pilot and Descriptive Observational Study

BACKGROUND

Digital health tools may facilitate the continuity of care. Enhancement of digital aid is imperative to prevent information gaps or redundancies, as well as to facilitate support of flexible care plans.

OBJECTIVE

The study presents Health Circuit, an adaptive case management approach that empowers health care professionals and patients to implement personalized evidence-based interventions, thanks to dynamic communication channels and patient-centered service workflows; analyze the health care impact; and determine its usability and acceptability among health care professionals and patients.

METHODS

From September 2019 to March 2020, the health impact, usability (measured with the system usability scale; SUS), and acceptability (measured with the net promoter score; NPS) of an initial prototype of Health Circuit were tested in a cluster randomized clinical pilot (n=100) in patients with high risk for hospitalization (study 1). From July 2020 to July 2021, a premarket pilot study of usability (with the SUS) and acceptability (with the NPS) was conducted among 104 high-risk patients undergoing prehabilitation before major surgery (study 2).

RESULTS

In study 1, Health Circuit resulted in a reduction of emergency room visits (4/7, 13% vs 7/16, 44%), enhanced patients' empowerment (P<.001) and showed good acceptability and usability scores (NPS: 31; SUS: 54/100). In study 2, the NPS was 40 and the SUS was 85/100. The acceptance rate was also high (mean score of 8.4/10).

CONCLUSIONS

Health Circuit showed potential for health care value generation and good acceptability and usability despite being a prototype system, prompting the need for testing a completed system in real-world scenarios.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04056663; https://clinicaltrials.gov/ct2/show/NCT04056663.

Prevention of Unplanned Hospital Admissions in Multimorbid Patients Using Computational Modeling: Observational Retrospective Cohort Study

BACKGROUND

Enhanced management of multimorbidity constitutes a major clinical challenge. Multimorbidity shows well-established causal relationships with the high use of health care resources and, specifically, with unplanned hospital admissions. Enhanced patient stratification is vital for achieving effectiveness through personalized postdischarge service selection.

OBJECTIVE

The study has a 2-fold aim: (1) generation and assessment of predictive models of mortality and readmission at 90 days after discharge; and (2) characterization of patients' profiles for personalized service selection purposes.

METHODS

Gradient boosting techniques were used to generate predictive models based on multisource data (registries, clinical/functional and social support) from 761 nonsurgical patients admitted in a tertiary hospital over 12 months (October 2017 to November 2018). K-means clustering was used to characterize patient profiles.

RESULTS

Performance (area under the receiver operating characteristic curve, sensitivity, and specificity) of the predictive models was 0.82, 0.78, and 0.70 and 0.72, 0.70, and 0.63 for mortality and readmissions, respectively. A total of 4 patients' profiles were identified. In brief, the reference patients (cluster 1; 281/761, 36.9%), 53.7% (151/281) men and mean age of 71 (SD 16) years, showed 3.6% (10/281) mortality and 15.7% (44/281) readmissions at 90 days following discharge. The unhealthy lifestyle habit profile (cluster 2; 179/761, 23.5%) predominantly comprised males (137/179, 76.5%) with similar age, mean 70 (SD 13) years, but showed slightly higher mortality (10/179, 5.6%) and markedly higher readmission rate (49/179, 27.4%). Patients in the frailty profile (cluster 3; 152/761, 19.9%) were older (mean 81 years, SD 13 years) and predominantly female (63/152, 41.4%, males). They showed medical complexity with a high level of social vulnerability and the highest mortality rate (23/152, 15.1%), but with a similar hospitalization rate (39/152, 25.7%) compared with cluster 2. Finally, the medical complexity profile (cluster 4; 149/761, 19.6%), mean age 83 (SD 9) years, 55.7% (83/149) males, showed the highest clinical complexity resulting in 12.8% (19/149) mortality and the highest readmission rate (56/149, 37.6%).

CONCLUSIONS

The results indicated the potential to predict mortality and morbidity-related adverse events leading to unplanned hospital readmissions. The resulting patient profiles fostered recommendations for personalized service selection with the capacity for value generation.

The Assessment of Medical Device Software Supporting Health Care Services for Chronic Patients in a Tertiary Hospital: Overarching Study

BACKGROUND

Innovative digital health tools are increasingly being evaluated and, in some instances, integrated at scale into health systems. However, the applicability of assessment methodologies in real-life scenarios to demonstrate value generation and consequently foster sustainable adoption of digitally enabled health interventions has some bottlenecks.

OBJECTIVE

We aimed to build on the process of premarket assessment of 4 digital health interventions piloted at the Hospital Clinic de Barcelona (HCB), as well as on the analysis of current medical device software regulations and postmarket surveillance in the European Union and United States in order to generate recommendations and lessons learnt for the sustainable adoption of digitally enabled health interventions.

METHODS

Four digital health interventions involving prototypes were piloted at the HCB (studies 1-4). Cocreation and quality improvement methodologies were used to consolidate a pragmatic evaluation method to assess the perceived usability and satisfaction of end users (both patients and health care professionals) by means of the System Usability Scale and the Net Promoter Score, including general questions about satisfaction. Analyses of both medical software device regulations and postmarket surveillance in the European Union and United States (2017-2021) were performed. Finally, an overarching analysis on lessons learnt was conducted considering 4 domains (technical, clinical, usability, and cost), as well as differentiating among 3 different eHealth strategies (telehealth, integrated care, and digital therapeutics).

RESULTS

Among the participant stakeholders, the System Usability Scale score was consistently higher in patients (studies 1, 2, 3, and 4: 78, 67, 56, and 76, respectively) than in health professionals (studies 2, 3, and 4: 52, 43, and 54, respectively). In general, use of the supporting digital health tools was recommended more by patients (studies 1, 2, 3, and 4: Net Promoter Scores of -3%, 31%, -21%, and 31%, respectively) than by professionals (studies 2, 3, and 4: Net Promoter Scores of -67%, 1%, and -80%, respectively). The overarching analysis resulted in pragmatic recommendations for the digital health evaluation domains and the eHealth strategies considered.

CONCLUSIONS

Lessons learnt on the digitalization of health resulted in practical recommendations that could contribute to future deployment experiences.

Group discussion: Challenges and key elements to be addressed when transferring GP

In this group discussion, all speakers will participate in a group discussion. The moderator will launch questions to speakers, and attendees will be encouraged to make contributions to the group discussion.

Core Features of the GP to be transferred during JADECARE and transfer challenges

In this second presentation, the representatives of each of the four JADECARE oGPs, Jon Txarramendieta (Kronikgune, Basque Country, Spain), Josep Roca (August Pi i Sunyer Biomedical Research Institute, Catalonia, Spain), Manfred Zahorka (Optimedis AG, Germany) and Kuno Strand Kudajewski (Health Innovation Centre, Southern Denmark) will describe the main traits of the Core Features of their practices and the Next adopters that will transfer and adapt them highlighting the transfer challenges.

Prospective cohort study for assessment of integrated care with a triple aim approach: hospital at home as use case

Background

Applicability of comprehensive assessment of integrated care services in real world settings is an unmet need. To this end, a Triple Aim evaluation of Hospital at Home (HaH), as use case, was done. As ancillary aim, we explored use of the approach for monitoring the impact of adoption of integrated care at health system level in Catalonia (Spain).

Methods

Prospective cohort study over one year period, 2017–2018, comparing hospital avoidance (HaH-HA) with conventional hospitalization (UC) using propensity score matching. Participants were after the first episode directly admitted to HaH-HA or the corresponding control group. Triple Aim assessment using multiple criteria decision analysis (MCDA) was done. Moreover, applicability of a Triple Aim approach at health system level was explored using registry data.

Results

HaH-HA depicted lower: i) Emergency Room Department (ER) visits (p < .001), ii) Unplanned re-admissions (p = .012); and iii) costs (p < .001) than UC. The weighted aggregation of the standardized values of each of the eight outcomes, weighted by the opinions of the stakeholder groups considered in the MCDA: i) enjoyment of life; ii) resilience; iii) physical functioning; iv) continuity of care; v) psychological wellbeing; (vi) social relationships & participation; (vii) person-centeredness; and (viii) costs, indicated better performance of HaH-HA than UC (p < .05). Actionable factors for Triple Aim assessment of the health system with a population-health approach were identified.

Conclusions

We confirmed health value generation of HaH-HA. The study identified actionable factors to enhance applicability of Triple Aim assessment at health system level for monitoring the impact of adoption of integrated care.

Registration

ClinicalTrials.gov (26/04/2017; NCT03130283).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08496-z.

Actionable Factors Fostering Health valUe Generation and Scalability of Prehabilitation: A Prospective Cohort Study

IMPORTANCE

Prehabilitation has potential for improving surgical outcomes as shown in previous randomized controlled trials. However, a marked efficacy-effectiveness gap is limiting its scalability. Comprehensive analyses of deployment of the intervention in real-life scenarios are required.

OBJECTIVE

To assess health outcomes and cost of prehabilitation.

DESIGN

Prospective cohort study with a control group built using propensity score matching techniques.

SETTING

Prehabilitation unit in a Tertiary-care University hospital.

PARTICIPANTS

Candidates for major digestive, cardiac, thoracic, gynecologic or urologic surgeries.

INTERVENTION

Prehabilitation program, including supervised exercise training, promotion of physical activity, nutritional optimization and psychological support.

MAIN OUTCOMES AND MEASURES

The comprehensive complication index, hospital and intensive care unit length of stay and hospital costs per patient until 30 days after surgery. Patients were classified by the degree of program completion and level of surgical aggression for sensitivity analysis.

RESULTS

The analysis of the entire study group did not show differences in study outcomes between prehabilitation and control groups (n=328 each). The per-protocol analysis, including only patients completing the program (n=112, 34%), showed a reduction in mean hospital stay (9.9 (7.2) vs. 12.8 (12.4) days; P=0.035). Completers undergoing highly aggressive surgeries (n=60) additionally showed reduction in mean intensive care unit stay (2.3 (2.7) vs. 3.8 (4.2) days; P=0.021) and generated mean cost savings per patient of 3,092€ (32% cost reduction) (P=0.007). Five priority areas for action to enhance service efficiencies were identified.

CONCLUSIONS AND RELEVANCE

The study indicates low rate of completion of the intervention and identifies priority areas for re-design of service delivery to enhance effectiveness of prehabilitation.

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

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.

Health Outcomes from Home Hospitalization: Multisource Predictive Modeling

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.

Effect of astaxanthin in extenders on sperm quality and functional variables of frozen-thawed boar semen

The aim of the study was to determine whether the presence of astaxanthin (ASX) protects boar spermatozoa against damage related to cryopreservation. Pooled ejaculates extended in Beltsville Thawing Solution (BTS) were used. Three experiments were conducted: 1) sperm samples were pre-incubated overnight (17 °C) with ASX (0, 0.5, 5, 15 μM) prior to freezing and then frozen using cooling and thawing extenders supplemented with ASX (0, 0.5, 5, 15 μM); 2) sperm samples were treated with ASX (0, 0.5, 5, 15 μM) only during overnight pre-incubation (17 °C) prior to cryopreservation; and 3) a thawing extender was supplemented with ASX (0, 0.5, 5, 15 μM). The groups were as follows: control (C; no treatment), ASX 1 (0.5 μM), ASX 2 (5 μM) and ASX 3 (15 μM). Total (TM) and progressive (PM) motility was analyzed using CASA, while sperm viability, reactive oxygen species generation, lipid peroxidation and apoptoticlike changes were analyzed using flow cytometry. Sperm variables were evaluated prior to freezing as well as 30 and 150 min after thawing. In Experiment 1, the values of TM and sperm viability post-thaw were less in the ASX 3 than C group. In Experiment 2, there was no effect of ASX on any of the sperm variables evaluated, while in Experiment 3, apoptotic-like changes were less in the ASX 1 than C group. In conclusion, there was a subtle beneficial effect on cryopreserved boar spermatozoa after addition of ASX to thawing media.

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

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.

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

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).

Towards a European health research and innovation cloud (HRIC)

The European Union (EU) initiative on the Digital Transformation of Health and Care (Digicare) aims to provide the conditions necessary for building a secure, flexible, and decentralized digital health infrastructure. Creating a European Health Research and Innovation Cloud (HRIC) within this environment should enable data sharing and analysis for health research across the EU, in compliance with data protection legislation while preserving the full trust of the participants. Such a HRIC should learn from and build on existing data infrastructures, integrate best practices, and focus on the concrete needs of the community in terms of technologies, governance, management, regulation, and ethics requirements. Here, we describe the vision and expected benefits of digital data sharing in health research activities and present a roadmap that fosters the opportunities while answering the challenges of implementing a HRIC. For this, we put forward five specific recommendations and action points to ensure that a European HRIC: i) is built on established standards and guidelines, providing cloud technologies through an open and decentralized infrastructure; ii) is developed and certified to the highest standards of interoperability and data security that can be trusted by all stakeholders; iii) is supported by a robust ethical and legal framework that is compliant with the EU General Data Protection Regulation (GDPR); iv) establishes a proper environment for the training of new generations of data and medical scientists; and v) stimulates research and innovation in transnational collaborations through public and private initiatives and partnerships funded by the EU through Horizon 2020 and Horizon Europe.

Multimorbidity as a predictor of health service utilization in primary care: a registry-based study of the Catalan population

Background

Multimorbidity is highly relevant for both service commissioning and clinical decision-making. Optimization of variables assessing multimorbidity in order to enhance chronic care management is an unmet need. To this end, we have explored the contribution of multimorbidity to predict use of healthcare resources at community level by comparing the predictive power of four different multimorbidity measures.

Methods

A population health study including all citizens ≥18 years (n = 6,102,595) living in Catalonia (ES) on 31 December 2014 was done using registry data. Primary care service utilization during 2015 was evaluated through four outcome variables: A) Frequent attendants, B) Home care users, C) Social worker users, and, D) Polypharmacy. Prediction of the four outcome variables (A to D) was carried out with and without multimorbidity assessment. We compared the contributions to model fitting of the following multimorbidity measures: i) Charlson index; ii) Number of chronic diseases; iii) Clinical Risk Groups (CRG); and iv) Adjusted Morbidity Groups (GMA).

Results

The discrimination of the models (AUC) increased by including multimorbidity as covariate into the models, namely: A) Frequent attendants (0.771 vs 0.853), B) Home care users (0.862 vs 0.890), C) Social worker users (0.809 vs 0.872), and, D) Polypharmacy (0.835 vs 0.912). GMA showed the highest predictive power for all outcomes except for polypharmacy where it was slightly below than CRG.

Conclusions

We confirmed that multimorbidity assessment enhanced prediction of use of healthcare resources at community level. The Catalan population-based risk assessment tool based on GMA presented the best combination of predictive power and applicability.

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

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.

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

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 (VO₂peak), 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.

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

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.

ERS Presidential Summit 2018: multimorbidities and the ageing population

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 via multidisciplinary systems, new technologies and transition from end-of-life care to advanced care planning.

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

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).

Boar semen proteomics and sperm preservation

Recently numerous proteomic approaches have been undertaken to identify sperm and seminal plasma (SP) proteins that can be used as potential biomarkers for sperm function, including fertilization ability. This review aims firstly to briefly introduce the proteomic technologies and workflows that can be successfully applied for sperm and SP proteomic analysis. Secondly, we summarize the current knowledge about boar SP and the sperm proteome, focusing mainly on its relevance to sperm preservation procedures (liquid storage or cryopreservation) and their outcomes in terms of sperm function and fertility.

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

AIM

We hypothesize that training-induced changes in muscle oxygen saturation (StO₂ ) 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 (VO₂ )] and CWRE at 70% pretraining peak VO₂ , before and after 8-w training, were done in 10 healthy age-matched subjects (H) [80% men, 65(11) years, FEV₁ 105(14)%] and 16 COPD patients [94% men, 70(5) years, FEV₁ 46(11) %] encompassing the entire spectrum of disease severity, recruited in the outpatient clinics. NIRS was used to assess StO₂ in the 'vastus medialis' of the left quadriceps.

RESULTS

Pretraining CWRE decreased StO₂ (P<0·05) and generated marked StO₂ rebound (P<0·001) after unloading in the two groups. After training, VO₂ peak increased in H [253(204) ml min^-1 ] (P<0·01) and in COPD [180(183) ml·min^-1 ] (P = 0·01) and blood lactate fell [-4·4 (2·7) and -1·6(2·3) mmol·m^-1 ] (P<0·05 each). Training generated a further fall in StO₂ during CWRE [-10(12)% and -10(10)%, P<0·05] and increased StO₂ rebound after unloading [8(7)% and 5(9)%, P<0·05] in both groups.

CONCLUSION

Endurance training further decreased StO₂ during CWRE, similarly in both groups, likely due to training-induced enhancement of muscle O₂ transfer and utilization. Training-induced StO₂ fall during CWRE may be useful individual marker for non-invasive assessment of enhanced muscle aerobic post-training function.

High pre-freezing sperm dilution improves monospermy without affecting the penetration rate in porcine IVF

The high incidence of polyspermy is still an unresolved problem for the production of in vitro-produced porcine embryos. In this work, we modified the usual sperm processing sequence for in vitro fertilization (IVF), and the spermatozoa from four boars were frozen directly at a low sperm concentration of 20 × 10⁶ sperm/mL (high pre-freezing sperm dilution group; F20), thawed and processed for IVF in three replicates. Spermatozoa from the same boars frozen at a conventional concentration (1000 × 10⁶ sperm/mL) were used as the control group. The post-thaw sperm quality evaluation demonstrated that despite there being no differences in the percentage of motile spermatozoa between groups, the proportion of live spermatozoa with intact acrosomes was significantly higher in the F20 group than in the control. The in vitro penetration rate was also similar between groups; however, the co-incubation of oocytes with F20 sperm increased monospermy, IVF efficiency, cleavage rate and the efficiency of blastocyst formation compared with the results for oocytes co-incubated with control spermatozoa. These results indicate, for the first time, that a high pre-freezing sperm dilution increases monospermy without affecting penetration rates, thereby increasing blastocyst formation.

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

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.

Paradigm changes for diagnosis: using big data for prediction

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).

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

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.

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

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.

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

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.

Meal composition influences postprandial sensations independently of valence and gustation

BACKGROUND

Palatability of meals with identical composition has been shown to influence postprandial sensations. Our aim was to determine to what extent meal composition influences postprandial sensations independently of palatability.

METHODS

Randomized, crossover, double-blind trial comparing the postprandial responses to a low-fat vs a high-fat test meal, with the same physical and organoleptic characteristics (taste, smell, texture, color, and temperature). The test meal consisted in 150 g hummus containing either 17.7 g fat (low-fat) or 22.3 g fat (high-fat), 19.8 g toasts, 120 mL water and 50 g apple puree. In 12 non-obese healthy men, palatability, homeostatic sensations (hunger/satiety, fullness) and hedonic sensations (digestive well-being, mood) were measured on 10 cm scales before and during the 60-min postprandial period. Comparisons between meals were performed with a two-way repeated measures ANCOVA with premeal data as co-variate.

KEY RESULTS

Both test meals were rated equally palatable (palatability scores 3.8 ± 0.3 low-fat, 3.3 ± 0.2 high-fat; P = .156). As compared to the high-fat meal, the low-fat meal induced more satisfaction (meal effect on well-being F(1,21) = 4.92; P = .038) and tended to improve mood (meal effect F(1,21) = 3.02; P = .064), and this was associated with a non-significant decrease in satiety (meal effect F(1,21) = 2.29; P = .145) and fullness (meal effect F(1,21) = 1.57; P = .224).

CONCLUSIONS AND INFERENCES

The composition of meals with equal palatability influences postprandial satisfaction, even without significant impact on homeostatic sensations, although an effect on homeostatic sensations has not been excluded. These conditioning factors may have clinical implications in patients with impaired meal tolerance or meal-related symptoms.

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

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.

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

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.

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

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.

Network modules uncover mechanisms of skeletal muscle dysfunction in COPD patients

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, FEV₁ 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 (VO₂ peak, Watts peak, BODE index and blood lactate levels) (P < 0.05 each), but not with lung function (FEV₁). 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

Electronic supplementary material

The online version of this article (10.1186/s12967-018-1405-y) contains supplementary material, which is available to authorized users.

Education of the postprandial experience by a sensory-cognitive intervention

BACKGROUND

Ingestion of a meal induces homeostasis-related sensations (satiety/fullness) that have a hedonic dimension (satisfaction/mood). We have previously shown that a previous physiological intervention, a meal preload, influences the responses to a subsequent meal, specifically: it increases satiety/fullness and decreases satisfaction. We now wished to determine the differential effects of education on the homeostatic and hedonic postprandial experience.

METHODS

Randomized, parallel study comparing the effect of real vs sham education on the responses to a probe meal. In two groups of healthy subjects (n = 14 each), homeostatic (satiety, fullness) and hedonic sensations (digestive well-being, mood) in response to a probe meal (250 mL soup, 25 g bread) were measured on 2 separate days before and after a single sensory-cognitive educational intervention (taste recognition test of supra- and sub-threshold tastands for real and sham education, respectively).

KEY RESULTS

Before education, in both groups the probe meal induced homeostatic sensations (satiety, fullness) with a positive hedonic dimension (increased digestive well-being and mood). In contrast to sham education, real education enhanced both homeostatic and hedonic responses to the probe meal (P < .05 vs sham education for all).

CONCLUSIONS AND INFERENCES

Education modifies the subjects' receptiveness and influences the responses to a meal, not only the hedonic postprandial experience, but also homeostatic sensations. Since homeostatic and hedonic responses are dissociable, education might be tailored to target different conditions.

Accident ahead? Difficulties of drivers with and without reading impairment recognising words and pictograms in variable message signs

A timely and accurate acquisition of the information provided by variable message signs (VMS) can be crucial while driving. In the current study, we assess the difficulties of adults with dyslexia acquiring the information shown in VMS and provide evidence to discuss the controversial use of pictograms as potential countermeasures. Twenty-two adults with dyslexia and 22 matched controls completed a simulated driving session. The legibility of 12 VMS was assessed, including six text messages (e.g. "ACCIDENT") and six single pictograms (e.g. the icon for "accident ahead"). On average, participants with dyslexia started reading text messages when they were closer to the VMS. In addition, while approaching text VMS, they dedicated more gazes and manifested worse control of speed. Regarding pictogram VMS, we observed no differences in response distance, accuracy, response duration, or number of gazes. To sum up, the evidence provided reveals that adults with dyslexia, despite potential compensation effects, may still find difficulties reading text messages in VMS (shorter legibility distances, longer reading times, and increased cognitive effort), whereas we found no such differences in the recognition of pictograms (only some difficulties keeping a steady speed). Research on inclusive measures to improve reading in low-skilled or dyslexic drivers must be encouraged.