RESUMEN
Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is an important part of the disease's morbidity, mortality, and progression, and is associated with increasing utilization of health care resources. The concept of integrated care based on a chronic care model is relatively new to chronic obstructive pulmonary disease, but has proved successful in improving clinical outcomes and probably in decreasing health care utilization in other chronic conditions. A comprehensive approach is needed to target a change in behavioral patterns in patients, increase physician's awareness and adherence to evidence-based recommendations, and address system related issues. This article discusses the evidence for various facets of nonpharmacological management of AECOPD and proposes a model of care that might be the missing link for reducing hospital readmissions for AECOPD. This model may decrease the morbidity, slow disease progression, and curb the increasing health care resource utilization without compromising patient care.
Asunto(s)
Continuidad de la Atención al Paciente/organización & administración , Readmisión del Paciente/estadística & datos numéricos , Enfermedad Pulmonar Obstructiva Crónica/terapia , Factores de Edad , Concienciación , Comorbilidad , Progresión de la Enfermedad , Volumen Espiratorio Forzado , Adhesión a Directriz/organización & administración , Conductas Relacionadas con la Salud , Estado de Salud , Humanos , Cooperación del Paciente , Alta del Paciente , Educación del Paciente como Asunto/organización & administración , Guías de Práctica Clínica como Asunto , Enfermedad Pulmonar Obstructiva Crónica/tratamiento farmacológico , Factores de Riesgo , Autocuidado , Apoyo Social , Factores SocioeconómicosRESUMEN
BACKGROUND: Acute pulmonary embolism (PE) is a life-threatening condition. Making a definitive diagnosis with radiologic studies may delay therapy or be unsafe for the patient. Echocardiography is readily available and can suggest PE by demonstrating right ventricular (RV) dysfunction. McConnell's sign on echocardiogram (ECHO-CG) (RV dysfunction with characteristic sparing of the apex) has been reported to have high sensitivity and specificity for the diagnosis of acute PE. It is hypothesized that McConnell's sign on ECHO-CG in patients hospitalized with suspected acute PE would have a high positive predictive value (PPV). METHODS: Data, from 2005 to 2010, were retrospectively collected on all patients with an ECHO-CG interpreted as revealing McConnell's sign, who had undergone another diagnostic study (computed tomography pulmonary angiography, ventilation-perfusion scan, upper or lower extremity Doppler ultrasound, or autopsy) for venous thromboembolic disease (VTE). The PPV on transthoracic ECHO-CG was calculated for the diagnostic accuracy of McConnell's sign in all patients. To minimize the potential for ECHO-CG reader bias of patients already confirmed to have had a PE by another modality, the PPV was then recalculated only on the patients in whom the ECHO-GM was the first diagnostic study. RESULTS: Seventy-three patients had findings of McConnell's sign on ECHO-CG. The PPV of McConnell's sign on ECHO-CG was 57% (CI, 45%-67%). Of the 37 patients who underwent an ECHO-CG in the first study for suspected acute PE, 15 patients had VTE confirmed; the PPV in this subset was only 40% (CI, 24%-56%). There were 20 patient deaths overall; of these, only 9 of the patients were confirmed to have VTE. CONCLUSION: We concluded that the presence of McConnell's sign has a relatively poor PPV for the diagnosis of acute PE and should not be used in isolation when making a diagnosis of PE in patients.