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A comparison of primary care physicians and pneumologists in the management of asthma in Spain: ASES study
ARTICLE IN PRESS Respiratory Medicine (2003) 97, 872–881
A comparison of primary care physicians and pneumologists in the management of asthma in Spain: ASES study ! * a,*, J. Enrique Cimasb, Concepcio! n D!ıaz Sa! nchezc, Antolin Lopez-Vi na Gemma Coriad, Onofre Vegazoe, Cesar Picado Vallesfon behalf of Scientific Committee of ASES study Servicio de Neumolog!ıa, Cl!ınica Puerta de Hierro, C/San Martin de Porre! s, 4, Madrid 28035, Spain ! 33210, Spain Primary Health Care Center of Contrueces, C/Rio Cares s/n, Gijon c * * s/n, Gijo! n 33394, Spain Servicio de Neumolog!ıa, Hospital de Cabuenes, C/Cabuenes d Primary Health Care Center of La Calzada, C/Oriental 11, Gijo! n 33212, Spain e Medical Department, AstraZeneca Farmace! utica Spain, S.A., C/Serrano Galvache, 56, Madrid 28033, Spain f Servicio de Neumolog!ıa, Hospital Clinic, C/Villarroel, 170, Barcelona 08036, Spain a
b
KEYWORDS Asthma; Management; Epidemiology; Pneumologists; Primary care; Spain
Summary The purpose of the ASES study is to determine the clinical characteristics of Spanish asthmatic patients seen in primary care (PC) and in pneumology (P) departments, comparing the availability of diagnostic methods, morbidity, the type of treatment and follow-up between the two health care settings. ASES is a multicenter, descriptive, cross-sectional study. The physicians were selected by random sampling. The data were collected by the participating physicians using three questionnaires. Data were collected on 2349 asthmatic patients (1298 from hospitals and 1051 from PC). Smokers predominated in the PC setting (P ¼ 0:000). The spirometry was performed at least once a year in 87.2% of the patients seen in P and 39.8% in PC (P ¼ 0:000). Morbidity was high in both groups (P and PC), more than two nighttime awakenings per month (25.5% versus 29%) and emergency visits in previous year (26% versus 21%). A high percent of asthmatic patients was using both inhaled corticoids and long-acting b2 -agonists (49.5% versus 32%). The 30% of PC patients could not be classified into any step of the treatment. In Spain, the morbidity of disease is high, despite the large use of drugs. Objective monitoring tests have very limited use in PC. r 2003 Elsevier Science Ltd. All rights reserved.
Introduction An increase in asthma prevalence not attributable to improved diagnostic methods has been seen in many countries all over the world in recent *Corresponding author. Tel.: +34-913162240; fax: +34-913730535. * E-mail address: [email protected] (A. Lo! pez-Vina).
years.1,2 At the same time, a high morbidity has been detected which may be attributed, at least in part, to deficient patient medical care.3,4 Asthma is a potentially fatal disease,5 but most deaths could be avoided with preventive measures, particularly self-treatment protocols.6,7 Various studies indicate that asthmatics are inadequately treated in many countries.3,8–10 In order to improve medical care to asthma patients,
0954-6111/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0954-6111(03)00041-6
ARTICLE IN PRESS Management of Asthma in Spain
knowledge should be obtained of the situation of asthma in the setting where improvements are contemplated, identifying the diagnostic methods used, the control of the disease, and the characteristics of treatment and of the follow-up measures applied in routine clinical practice. Most asthmatic patients are treated by primary care (PC) physicians, both in Spain and elsewhere. The rest of patients are seen by specialists in pneumology (P), and only a small percentage are managed by other specialists (allergologists, internists).11,12 Some studies have found differences in the care of asthmatics by PC physicians or ‘‘specialists’’.13,14 These differences have been attributed to the time dedicated to the patients and to professional knowledge. It would therefore be desirable to know the differences between these two groups of physicians in Spain, with the aim of improving coordination between them in the care of asthmatic patients. One of the main problems for assessing adequate professional care is the lack of specific and universally accepted guidelines. In the case of asthma, national15 and international16 consensus, guidelines are available as a reference for all health care professionals involved in the management of asthmatic patients. The aim of our study is to determine the characteristics and clinical status of Spanish asthmatics seen in the PC and P settings, and to ascertain the existing differences in the availability of diagnostic methods, the morbidity rate, the type of treatment and the monitoring between the two health care settings.
Material and methods This is a multicenter, descriptive, cross-sectional study to collect data on the characteristics of asthmatic patients seen at PC offices and hospital P outpatient clinics throughout Spain. The ASES study was coordinated by a Scientific Committee composed of an Asthma Area delegate from the Spanish Society of Pneumology and Chest Surgery (Sociedad * Espanola de Neumolog!ıa y Cirug!ıa Tora! cica, SEPAR) and another from the Respiratory Group in Primary Care (Grupo de Respiratorio en Atencio! n Primaria, GRAP). In order to avoid seasonal bias, data on asthmatics were collected during two 4-month periods from October 1, 1998 to January 31, 1999 and from March 1, 1999 to June 30, 1999, respectively. PC physicians were selected by stratified random sampling in proportion to the regional population.
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To this effect, the Spanish territory was divided into five areas, excluding the non-mainland areas of the Canary Islands, the Balearic Islands, Ceuta and Melilla for logistical reasons. Pneumologists were selected by random block samplingFthe sampling unit in this case being the Department of Pneumology rather than the individual physician. A list was prepared by Autonomous Communities, selecting only those Departments of Pneumology belonging to hospitals ascribed to the public health care system (Table 1). All selected physicians were requested by mail to agree to participation in the study. Those who failed to give agreement were excluded, as were those whose occupational characteristics precluded adequate collaboration during the study (emergency care physicians and/or reinforcements, substitutions and physicians pending transfer). The excluded physicians were systematically replaced by the individual immediately following on the randomization list. The required sample size for maximum indetermination of the test parameters (p ¼ q ¼ 0:5), with a 95% confidence interval (CI) and a precision of 3%, was 1608 patients per study period, assuming 20% potential losses. The 134 PC physicians selected were required to collect information on 12 asthmatics systematically selected during the 4 months of each period (the first three patients attending each month for consultation concerning any aspect related to asthma, including prescriptions, etc.). Physicians who voluntarily withdrew during the study or who failed to respond or submit any data were not replaced and were regarded as non-responses. Fifty-eight Departments of Pneumology were selected, nine of which were divided into two units based on the population they covered, thus yielding a final total of 67 units. Each unit was requested to collect data from 15 patients systematically selected during the 4 months of each of the two periods, in a way similar to PC. Three questionnaires were prepared and sent to the selected PC and P physicians. One questionnaire was intended to record data concerning the organization and infrastructure at the different centres (location, population seen, availability of diagnostic means), and was completed by each professional once at the start of each period. Another questionnaire was designed to calculate the prevalence of asthma in the population seen (visits for asthma compared to the total visits during the study period), and was completed by the physician at the end of each period. Finally, the third questionnaire recorded the sociodemographic, diagnostic, morbidity and treatment data
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Population of Autonomous Communities. Population figures as of January 1, 1998, obtained from the corresponding municipal census statistics declared official by the Government authorities (Royal Decree 950/2001 of August 3).
18 17 17 8 7 67 37 34 33 15 15 134 27 25 25 11 11 100 10 382 728 9 558 800 9 418 787 4 339 626 4 096 440 37 796 381 Area Area Area Area Area
I II III IV V
* and Comunidad Valenciana Cataluna Extremadura, Andaluc!ıa and Murcia ! Madrid, Castilla-La Mancha and Castilla-Leon Galicia, Asturias and Cantabria ! Pa!ıs Vasco, Navarra, La Rioja and Aragon Total
% Regions
Population (no. of inhabitants)
Primary care physicians
Pneumology units
A. Lo ´pez-Vin ˜a et al.
Table 1 Proportional distribution of primary care physicians and pneumologists according to the population in each of the five geographic areas established.
874
of each patient studied, and was completed by the physician during the interview with each asthmatic. This last questionnaire also documented the patient spirometric and/or peak expiratory flow (PEF) values obtained on the day of the interview. The three questionnaires were subjected to pilot evaluation before the start of the study using 10 physicians pertaining to the health care area of ! (Asturias). Following this pilot period, some Gijon changes were made in the questionnaires in order to improve comprehensibility. If no response had been received 2 weeks after the deadline, the participants were contacted by telephone in an attempt to obtain the required information. Four months after the end of the last study period (i.e., October 31, 1999), data collection was definitively closed. A descriptive statistical analysis was made using means and standard deviations (SD) for the quantitative variables and proportions for the qualitative variables. For comparing the data from the PC and P settings, Student’s t-test was used for the quantitative variables, and a Z-test to compare proportions for the qualitative variables. The 95% CI were calculated in all cases. Bilateral statistical significance was considered for P ¼ 0:05 in all analyses. SPSS version 9.0 for Windows, Primer statistics 1.0, and CIA (Confidence Interval Analysis) 1.0 were used for statistical processing.
Results Of the selected samples, a total of 106 PC physicians started participation in the ASES study; 34 of these withdrew before the end of the studyFthe response rate therefore being 58% (n ¼ 72). As regards the P units, 79% responded (n ¼ 53). The potential differences between the physicians who completed both study periods and those who withdrew before completion were analyzed, and no significant differences were found in terms of age, sex, specialty, population size or geographic area. Data from 2349 asthmatic patients were collected (1051 in PC and 1298 in the P setting). The mean age was 46721 years in PC and 46719 years in P. There were significantly more smokers in PC than in P (P ¼ 0:000). The rest of the differences are shown in Table 2. The proportion of consultations for asthma with respect to total consultations was 32% in P and 4% in PC. Spirometry was performed at the time of consultation in 80% of the hospitals, while only 50% of the PC physicians had access to this
ARTICLE IN PRESS Management of Asthma in Spain
Table 2
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Sociodemographic characteristics of the asthmatic patients in both groups. Hospital
Age Sex Males Females Smoking Non-smoker Exsmoker Smoker Occupational status Unemployed Housewife Student Active Retired Early retirement
Primary care
P
No.
% (CI 95%)
No.
% (CI 95%)
1298
46 (44,6–47,1)
1051
46(44,6–46-,8)
NS
477 821
37 (34.1–39.4) 63 (60.6–65.9)
453 598
43 (40.1–46.1) 57 (53.9–59.9)
NS NS
946 251 101
73 (70.5–75.3) 19 (17.2–21.5) 8 (6.3–9.3)
691 181 179
66 (62.9–68.6) 17 (14.9–19.5) 17 (14.8–19.3)
0.0001 NS 0.0000
57 417 207 422 179 16
4 (3.3–5.6) 32 (29.6–34.7) 16 (14–17.9) 32.5 (30–35.1) 14 (11.9–15.7) 1 (0.7–2)
42 290 205 290 204 20
4 (2.9–5.3) 28 (24.9–30.3) 19.5 (17.1–21.9) 28 (24.9–30.3) 19 (17–21.8) 2 (1.1–2.9)
NS 0.01 0.02 0.01 0.0002 NS
diagnostic method. Among the latter, 25% could request spirometry directly from their specialized reference center, while the rest had no choice but to refer the patients elsewhere. On the other hand, 87% (CI: 85.4–89.0) of the patients seen in P were subjected to spirometry at least once a year, while spirometry was not performed at any time in only 3% (CI: 2.2–4.2). In PC, spirometry was carried out at least once a year in only 40% of the patients (CI: 36.8–42.7), and never in 23% (CI: 20.6–25.7). These differences were statistically significant (P ¼ 0:000). On the day of the interview, spirometry data were recorded in 1168 patients seen in P (90%; CI: 88.4–91.6), and PEF data in 898 (69%; CI: 66.7– 71.7). By contrast, in the PC setting, spirometric data were recorded in 341 patients (32%; CI: 29.6– 35.3), and PEF data in 159 (15%; CI: 13.0–17.3) (P ¼ 0:000). The spirometric values recorded were similar in both groups of patients. Thus, an FEV1 of over 80% of the theoretical value was recorded in 58% (CI: 55–60.7) of the P group and in 52% (CI: 46.3–56.9) of the PC group. In turn, an FEV1 of under 60% of the theoretical value was recorded in 18% (CI: 16.1–20.5) of the patients seen in P and in 21% (CI: 16.8–25.4) of those seen in PC. Finally, 24% (CI: 21.4–26.2) of the P group and 27% (CI: 22.5–32) of the PC group yielded FEV1 values between 60% and 80% of the theoretical value. The morbidity of asthmatic patients was high in both groups. It should be stressed that the P group
showed a greater number of visits to the emergency department, hospital admissions and admissions to intensive care units than the PC group. By contrast, the latter showed more work and school absenteeism and made greater daily use of short-acting b2 agonists (Table 3). Differences between the two groups were recorded in the type of medication used to treat asthma (Table 4). Thus, 90% (CI: 88–91.3) of the patients seen in P used inhaled corticoids versus 62.5% (CI: 59.6–65.4) of those seen in PC (P ¼ 0:000); budesonide was the most widely used drug in both groups. The P group also used significantly more long-acting b2 -agonists (56%, CI: 53.8–59.2) than the PC group (44%; CI: 41.2–47.2), as well as more short-acting b2 agonists (92%; CI: 90–93.1 versus 81.6%, CI: 79.3–84) (P ¼ 0:000 for both). However, other drugs were more widely used in PC (antihista= mines, nedocromil, ipratropium bromide and immunotherapy) (Po0:05). When grouped by associations and recommended doses, the PC group was seen to use fewer high-dose inhaled corticoids and in combination with long-acting b2 -agonists, and more non-classifiable treatments were administered (mucolytic agents, antitussive drugs) (Table 5). Some particularities were seen. Thus, 0.8% (CI: 0.3–1.4) of the patients seen in P used inhaled corticoids as needed, but this figure increased to 3% (CI: 1.9–4) in the PC group. By contrast, 26% (CI: 23–28.3) of the asthmatics seen in PC have been
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Table 3
A. Lo ´pez-Vin ˜a et al.
Morbidity data in each group of asthmatic patients.
Symptoms more than once a week More than two nighttime awakenings a month Work or school absenteeism Emergency visits in previous year Hospital admission in previous year Ever admitted to intensive care unit Daily use of short-acting b2 -agonists Oral corticoid cycles in the past 6 months
Hospital
Primary care
No.
% (CI 95%)
No.
% (CI 95%)
411 331 207 339 172 84 155 273
32 (29.1–34.2) 25.5 (23.1–27.9) 16 (14–17.9) 26 (23.7–28.5) 13 (11.4–15.1) 6.5 (5.1–7.9) 12 (10.2–13.7) 21 (18.8–23.2)
253 304 229 222 100 31 190 227
24 (21.5–26.7) 29 (26.2–31.7) 22 (19.3–24.3) 21 (18.7–23.6) 9.5 (7.8–11.5) 3 (2–4.1) 18 (15.8–20.4) 22 (19.1–24.1)
prescribed a short-acting b2 -agonist, as compared to only 2% (CI: 1.2–2.8) in the P group. Long-acting b2 -agonists were used without inhaled corticoids in 1% (CI: 0.5–1.8) of the patients seen in P and in 11% (CI: 8.7–12.4) of those seen in PC. In turn, 2% (CI: 1–2.6) of the PC group used long-acting b2 -agonists as needed, this figure dropping to 0.5% (CI: 0.1–1.1) in the P setting. It should also be mentioned that 3% (CI: 2.3–4.6) of the PC group (n ¼ 35) received theophylline as the only treatment, while this only occurred in two patients from the P group (0.1%; CI: 0.01–0.5). As regards other treatment measures, 75.5% (CI: 73.2–77.8) of the patients seen in P were given information on environmental measures to prevent asthma attacks, while this proportion increased to 81% (CI: 78.3–83.1) in PC. Likewise, written selftreatment plans were distributed among the patients in both health care settings: 66% (CI: 63.2–68.4) in the P group and 61.5% (CI: 58.5–64.4) in PC. By contrast, daily PEF measurements in the home were made by 25% (CI: 23–27.7) of the P patients versus only 5% (CI: 3.6–6.3) of those seen in PC (P ¼ 0:000).
Discussion This study addresses some aspects of asthma management in Spain from the perspective of the physician, and shows an inadequate use of objective measures for patient monitoring, a high morbidity and a high proportion of inadequate treatments. One limitation of the study is the high percentage (42%) of PC physicians who failed to respond, though this fact probably has little influence upon the results obtained, since no differences were
P
0.000 0.072 0.000 0.005 0.005 0.000 0.000 0.762
seen between the physicians who responded and those who did not. Other limitations are inherent to the crosssectional study design, using the medical diagnosis of asthma and therefore not including patients not diagnosed or those who do not visit the doctor. Thus, the results refer only to the clinical care of patients diagnosed of asthma who regularly visit their physician (consulting population). It has not been possible to take into account the severity of asthmatic patients as it was not possible to classify them according to clinical and functional criteria given that most of them were on treatment. Therefore, the comparison between both populations (PC and P) has this constraint; although it is important, we considered it to be of little relevance to the objective of the study which was to describe the situation in each one the health care settings. One of the most striking findings of the study is the scant use made in the PC setting of objective measures to monitor asthmatic patients. Thus, spirometry is never performed to one-quarter of asthmatic patients, while in 60% of the cases spirometry is never done or is performed less than once a year. These observations contrast with the recommendations of the guidelines for asthma treatment,15,16 where emphasis is placed on the significance of assessing pulmonary function in the monitoring of asthmatic patients. Such functional assessment is advised at least once a year, and ideally whenever the patient is seen. The PEF meter can replace spirometry when the latter is not available, but this simple and inexpensive device is used even less than spirometry. One of the aims of treatment is to achieve a pulmonary function that is normal or as normal as possible. However, this objective is difficult to achieve if pulmonary function is not even tested. It
92 87
87 42 45
38
Other bronchodilators Theophylline Ipratropium bromide
Oral corticoids Total Prednisone Deflazacort
Other drugs Total
226
733 432 301
Long-acting b2 -agonists Total Salmeterol Formoterol
Immunotherapy at any time Total
1189
2 21 117 19
1164 56 814 294
Short-acting b2 -agonists Total
Other antiinflammatory agents Cromoglycate Nedocromil Antileukotrienes Antihistamines
Inhaled corticoids Total Beclomethasone Budesonide Fluticasone
17 (15.3–19.5)
3 (2–4)
7 (5.4–8.2) 3 (2.3–4.3) 3.5 (2.5–4.6)
7 (5.7–8.6) 7 (5.4–8.2)
56.5 (53.8–59.2) 33 (30.7–35.8) 23 (20.9–25.5)
92 (90–93.1)
0.1 (0.01–0.5) 2 (1–2.4) 9 (7.5–10.7) 1.5 (0.8–2.2)
90 (88–91.3) 4 (3.2–5.5) 63 (60.1–65.3) 23 (20.4–24.9)
253
114
42 5 37
99 99
465 342 123
858
5 36 67 121
657 99 440 118
No.
No.
% (CI 95%)
Primary care
Hospital
Table 4 Drugs used for the treatment of asthmatic patients.
24 (21.5–26.7)
11 (8.9–12.7)
4 (2.9–5.3) 0.5 (0.1–1.1) 3.5 (2.5–4.8)
9 (7.7–11.3) 9 (7.7–11.3)
44 (41.2–47.2) 32.5 (29.7–35.4) 12 (9.7–13.6)
82 (79.3–84)
0.5 (0.1–1.1) 3 (2.4–4.7) 6 (4.9–8) 11.5 (9.5–13.4)
62.5 (59.6–65.4) 9 (7.7–11.3) 42 (38.9–44.8) 11 (9.3–13.1)
% (CI 95%)
0.000
0.000
0.006 0.000 0.910
0.051 0.020
0.000 0.714 0.000
0.000
0.152 0.007 0.024 0.000
0.000 0.000 0.000 0.000
P
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Management of Asthma in Spain 877
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Table 5
A. Lo ´pez-Vin ˜a et al.
Type of treatment used in each group of asthmatic patients.
No treatment Only short-acting b2 -agonists as needed Low-dose inhaled corticosteroidsa High-dose inhaled corticosteroidsb Inhaled corticosteroids+long-acting b2 -agonists Oral corticosteroids Non-classifiable a
Hospital
Primary care
No
% (CI 95%)
No
% (CI 95%)
4 87 174 227 643 88 75
0.3 (0.07–0.7) 7 (5.4–8.2) 13(11.6–15.3) 17 (15.4–19.6) 49.5 (46.8–52.3) 7 (5.4–8.2) 6 (4.5–7.1)
17 113 133 92 335 42 319
2 (0.9–2.5) 11 (8.8–12.6) 13 (10.6–14.7) 9 (7.1–10.6) 32 (29.1–34.7) 4 (2.9–5.3) 30 (27.6–33.1)
P
0.002 0.000 0.661 0.000 0.000 0.006 0.000
Low-dose inhaled corticosteroidsp500 mg/day of beclomethasone or budesonidep250 mg/day of fluticasone. High-dose inhaled corticosteroidsX500 mg/day of beclomethasone or budesonideX250 mg/day of fluticasone.
b
could be thought that the reason for this is a lack of spirometers and PEF meters, but the reason is more likely to be that physicians are unaware of their importance or simply consider them of little value, since access at least to a PEF meter is usually easy and cheap. In the P units the situation is different, since only 3.2% of the patients were never subjected to spirometry, and over 80% were evaluated by this technique at least once a year. This lack of use of pulmonary function test agrees with the Spanish data of the AIRE study,17 where 65% of all patients reported never having been subjected to spirometry, and an additional 26% said that no such study had been made on them in the previous year. These figures are higher than the European averages. Therefore, from the patient perspective (the AIRE data were collected from the patients), the problem is even worse. It is most probable that the patients seen in P are more severe than the patients seen in PC as the indirect data (greater number of visits to the emergency room and of hospitalizations as well as a greater number of patients receiving treatment with high doses of corticosteroids and these in combination with long-lasting b2 -agonists) are indicative of this. In any case as in other studies, patient morbidity was high17,18 in both the PC and P setting. More than 25% of the asthmatics woke up at night two or more times a month, while 19% missed work or school, 24% visited the emergency department in the previous year, and 12% were admitted to hospital in the previous year because of asthma. One of the reasons for poor asthma control is prescription of inadequate treatment,19,20 though this does not seem to have been the main cause in our study, at least in the population seen in the P units (90% were receiving inhaled corticoids, and 94% could be classified on some severity stage). Inadequate treatment could have been the cause of high morbidity in only 30% of patients seen in PC
who could not be classified in any severity stage, but in the remaining 70% inadequate therapy does not seem to be the main cause either. Inadequate monitoring of therapeutic objectives and poor treatment compliance could be the reasons for this discrepancy between morbidity and treatment. In the AIRE study,17 only 15% of the patients were receiving inhaled corticoids. The difference between what the physicians claim to be prescribing and what the patients claim to be receiving is too great, and suggests that poor patient compliance is one of the causes of high morbidity. An interesting finding is the existence among the asthmatics seen in PC of more than twice as many smokers as in P. These data are similar to those found in two studies conducted in Australia and the United States,13,14 but which the authors overlook. One reason could be that hospitals deal with the more serious asthma cases, who do not smoke because of the severity of their disease (the percentage of former smokers is similar), but another possible explanation is that PC physicians and the smoking asthmatics themselves attribute the symptoms to smoking and consequently request less hospital intervention. In the European study,21 smoker status was strongly associated with nonacknowledgement of the disease, thus suggesting that the symptoms are attributed to smoking, as a result of which the patient does not report to the doctor. Even after diagnosis, the patients at least partially continue to blame the symptoms on smoking. One study has shown that asthmatic children with smoking parents are not adequately treated22 because the parents tend to take them less to see the doctor. Taken together, all these data suggest that tobacco smoking appears to lead to deficient management of asthmatic patients, the responsibility for this situation possibly being distributed among the parents, patients and physicians. Medical professionals should take this aspect
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into account, retaining asthma control as the primary treatment aim even if the patient smokes. PEF monitoring is recommended for the followup of asthmatic patients.15,16 In this study, only one-fifth of the asthmatics seen in PC used the PEF meter at home, as compared to 25% of those seen in the P setting. Both proportions are very low. Surprisingly, the physicians claim that most patients have received self-treatment instructions. This data agree with those of the AIRE study, according to which Spain is the participating European country with the largest percentage of patients with self-treatment plans. We have no explanation for this finding, but an erroneous understanding of what is meant by a self-treatment plan may be responsible, together with the misconception that b2 -agonist rescue medication constitutes such a plan. The low proportion of patients with PEF monitoring suggests that in fact few self-treatment plans contemplate increased inhaled corticoids or the use of oral corticoids under certain circumstances. Such plans are the ones actually having an impact upon asthma morbidity and mortality.6 The differences between PC and P in the way the pulmonary function test was used may reflect differences the working conditions (less time available per patient, less spirometers) and the fact that there is less specific training in PC. To improve this situation a better cooperation would be necessary between the two health care settings as well as the development of ongoing training programmes in PC. To summarize, objective methods used are very little in PC for the monitoring of asthmatic patients. Morbidity associated with the disease is very high both in the PC and P setting, possibly due to inadequate monitoring of therapeutic objectives by health professionals and to poor patient compliance with treatment, due to a lack of educational strategies for improving patient adhesion. The improved care of asthmatic patients in Spain therefore requires an increased use of objective monitoring tests in PC (i.e., spirometers and PEF meters). Moreover, in both PC and P, emphasis should be placed on the need to monitor the established therapeutic objectives and the convenience of implementing patient education programs to afford increased patient autonomy and better treatment compliance.
Acknowledgements The authors acknowledge the effort of all investigators participating in the ASES study, and thank
879 ! ASTRAZENECA Farmaceutica Spain, S.A., which financed the logistic aspects of the study and granted two scholarships for a pneumologist (Dr ! D!ıaz) and a primary care physician (Dr Concepcion Gemma Coria), who centralized data reception and tabulation.
Appendix A. Pneumologists participating in the ASES study Concha Pellicer, Hospital Francesc de Borja (Gand! Aguero, ! de Valdecilla !ıa); Ramon . Hospital Marques (Cantabria); Jose! Ma Ignacio Garc!ıa, Hospital General Serran!ıa (Ronda); Santiago Bardaji Hospital Sant Jaume (Mataro! ); Luis Border!ıas, Hospital San ! Jorge (Huesca); Luis Perez del Llano, Hospital Xeral (Lugo); Ma Jose! Linares, Hospital Virgen de las * Nieves (Granada); Jose! Luis Viejo Banuelos, Hospi. (Burgos); Eduardo Garc!ıa Pacho! n, tal General Yague ! Hospital Vega Baja (Orihuela); Manuel Perez de las Casas, Hospital de Navarra; Celso Alvarez Alvarez, Hospital Instituto Nacional de Silicosis (Asturias); * de Federico Manresa, Hospital Pr!ıncipes de Espana Bellvitge (Barcelona); Inmaculada Alfageme, Hospital de Valme (Sevilla); Rafael Vah!ı Maqueda, Hospital Osuna (Sevilla); Luis Marco Jorda! n, Hospi! tal de Guipuzcoa; Carmen Montero Mart!ınez, ! * Hospital Juan Canalejo (La Coruna); Antol!ın Lopez * * Vina, Hospital Cabuenes (Asturias); Alfredo de Diego, Hospital La Fe (Valencia); Carlos Villasante, Hospital La Paz (Madrid); Agust!ın Sojo Gonza! lez, Hospital San Pedro de Alca! ntara (Ca! ceres); Aurelio Valencia, Hospital Carlos Haya (Ma! laga); Ignacio Ma Sa! nchez, Hospital General (Guadalajara); Javier Tamayo, Ambulatorio del Hospital Ramo! n y Cajal (Madrid); Joan Serra Batlles, Hospital General de Vic (Barcelona); Manel Rubio Godoy, Hospital Josep Trueta (Girona); Rosa Sa! nchez Gil, Hospital Virgen del Roc!ıo (Sevilla); Fernando Fuentes Otero, Hospital Infanta Cristina (Badajoz); Salvador Herna! ndez Flix, Hospital Sant Joan (Reus); Xavier Aguilar, Hospital Joan XXIII (Tarragona); Jose! Luis AlvarezSala Walker, Hospital Cl!ınico (Madrid); Julio Ancochea, Hospital La Princesa (Madrid); Ma Jose! Ferreiro, Hospital Puerta de Hierro (Madrid); Juan Guallar Ballester Hospital La Magdalena (Castell! on); Patricia Lloberes, Hospital Valle d’Hebro! n (Barcelona); Jose! Luis Carretero Sastre, Hospital R!ıo Ortega (Valladolid); Ma Angeles Ferandez Jorge, Hospital R!ıo Carrio! n (Palencia); Nicola! s Gonza! lez Mangado, Hospital Concepcio! n (Madrid); Pedro Mart!ın Escribano, Hospital Doce de Octubre
ARTICLE IN PRESS 880 ! Martinez-Moratalla Rovira, Hospital (Madrid); Jesus ! Hospital General (Albacete); Cesar Picado, Hospital Clinic (Barcelona); Vicente Plaza, Hospital Santa Creu i Sant Pau (Barcelona); Eusebi Chiner, * Hospital San Juan (Alicante); Luis Pineiro Amigo, Hospital Xeral Cies (Pontevedra); Juan Ga! ldiz, Hospital Cruces (Vizcaya); Joaqu!ın Lamela, Hospital * (Orense). Cristal-Pinor
Primary care physicians participating in the ASES study Blas Cloquell Rodrigo, C.S. Florida (Alicante); Ma Angeles Cabrera Ferriols, C.S. Hospital Provincial Alicante; Ramon Anto! n Torres, C.S. Crevillent; * Ernesto Vines Martinez, C.S. Petrer; Margarita Ayala Rullan, C.S. Javea (Xabia); Karlos Naberan * C.S. Clot (Barcelona); Angel Cano Romero, Tona, C.S. Bon Pastor (Barcelona); Eva Tarrats Feliu, C.S. Creu Alta (Sabadell); Jose Antonio Dom!ınguez del Rio Ambulatorio Vilafranca del Penedes; Francisco Cebrian Montolio, C.S. 9 de Octubre (Castello! n); Remei Girona Bastus, C.S. Dr. Vilaplana-Taila (Girona); Susana Sarriegui Dominguez, C.S. La Bordeta (Lleida); Ma Antonia Navarro Echeverria, C.S. Borges Blanques; Roland Juan Franquet, C.S. Sant Carles de la Rapita; Carmen Mas Tomas, C.S. Economista Gay Valencia; Elisa Flecha FernandezCouto, C.S. Trinitat (Valencia); Tomas Paga Bueso, C.S. Trinitat (Valencia); Carlos Bonora Xerri, C.S. Concordia (Burjasot); Juan Luis Castillo Lopez, C.S. Anexo II (Badajoz); Augusta Albarran Sanz-Calcedo, C.S. Pueblo Nuevo del Guadiana; Maria Soledad Iglesias Campos, C.S. Zafra I; Purificacion Herrera Valdes, C.S. Nicola! s Perez Jimenez (Cabeza del Buey); Manuel Prieto Oliva, C.S. Hervas; Jose Antonio Rodr!ıguez Iglesias, C.S. Algeciras-Norte; Juan Candau Camacho, C.S. San Telmo (Jerez de la Frontera); Emilio Sa! nchez Caballero, C.S. Baena; Ma Rosa Palomar Alguacil, C.S. de Lucena; Salvador Mart!ınez Puentedura, C.S. Motril Centro; Encarna * Luis Antonio Ferna! ndez Diaz Diaz, C.S. Salobrena; Saura, C.S. Ronda-Norte; Natividad Ferna! ndez Perea, C.S. de Mula; Antonio Matias Urrea Andreu, C.S. San Vicente (Cartagena); Juan Fco. Menarguez Puche, C.S. Molina de S; Francisco Belda Marhuenda, C.S. Archena/Cons.Villanueva (Archena/Villanueva del Segura); Francisca Matilde Lopez Lara, C.S. Alcala! Guadaira; Pedro Ros Sanchez Cruzado, C.S. Torreon (Ciudad Real); Ramzi Jamil Ala, C.S. Daimie-I; Laureano Go! mez Gonzalez, C.S. Campo * Castrillo San Jose, C.S. de Criptana; Begona Benavides de Orbigo; Andres Castillejo Alvarez, C.S. Canillas-Prosperidad (Madrid); Margarita Gonz-
A. Lo ´pez-Vin ˜a et al. a! lez Polo, C.S. Hermanos Miralles (Madrid); Esther Picazo Gomez, C.S. los Almendrales (Madrid); Isabel Garc!ıa Lazaro, C.S. Ciudad de los Periodistas ! (Madrid); Pilar Gomez Perez, C.S. Pa! rroco Julio * Morate (Madrid); Ana Pastor Rodriguez Monino, C.S. Juan de Vera (Madrid); Olvido la Torre Rodriguez, C.S. Pinto; Silvia Kieckebwsch Kuserow, C.S. Fron! Moreno, teras (Torrejon de Ardoz); Ma Jose Alvarez C.S. Dr. Granero (Alcorcon); Almudena Paredes Garcia, C.S. Jardinillos (Palencia); Jose Antonio Iglesias Valiente, C.S. Alamedilla (Salamanca); Juan Manuel de Andres Rubio, C.S. Sepulveda; Isabel Perez Ortega, C.S. Almazan; Jose! Luis Turabian Ferna! ndez, C.S. Benquerencia-Poligono (Toledo); Mercedes Redondo Valdeolmillos, C.S. Magdalena (Valladolid); Ana Carvajal de la Torre, C.S. Federico * Tapia (La Coruna); Maelba Veleiro Fernandez, C.S. Vilalba; Miguel Angel Lo! pez Ortiz, C.S. Ponte (Orense); Celia Rodr!ıguez Perez, C.S. Ponte (Orense); Ernesto Mart!ınez Estrada, C.S. La Calzada ! (Gijon); Arturo de la Vega Cuyas, C.S. La Magdalena (Aviles); Tomas Gutierrez Renedo, C.S. Villalegre (Aviles); Froilan Gutierrez de Diego, C.S. Lugones (Lugones); Victoria Sa! nchez Ventin, C.S. Beiramar (Vigo); Julia Bo! veda Fontan, C.S. Pintor Colmeiro (Vigo); Maria Carmen Perez del Oso, C.S. Polanco; Roman Ganzara!ın Gorosabel, C.S. Ibarra; Luis * Ferna! ndez Urzainqui, C.S. Baranain; Jose! Antonio Iruretagoyena Amiano, C.S. de Elizondo; Leonor Aurrekoetxea Bildosola, C.S. Santutxu (Bbilbao); * Victoria Astobiza Arino, C.S. Zurbaran (Bilbao); Roberto Gonza! lez Guerra, C.S. Kueto Sestao; Ma Luisa Gutierrez Ibarzabal, C.S. Leioa.
References 1. The International Study of Asthma and Allergies Childhood (ISAAC) Steering Committee. Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. Lancet 1998;351:1225–32. 2. Sears M. Descriptive epidemiology of asthma. Lancet 1997;35:s1–27. 3. Jansen C, Chinn S, Jarvis D, Burney P. Physician-diagnosed asthma and drugs utilitation in the European Community Respiratory Health Survey. Eur Respir J 1997;10:1795–802. 4. Legarreta AP, Chistian-Herman J, O’Connor RD. Compliance with national asthma management guidelines and speciality care: a health maintenance organitation experience. Arch Intern Med 1998;9:457–64. 5. British Thoracic Association. Death from asthma in two regions of England. Br Med J 1982;285:1251–5. 6. Abramsen MJ, Bayley MJ, Couper FJ, et al. Are asthma medications and management related to deaths from asthma? Am J Respir Crit Care Med 2001;163:12–8. 7. Beasley R, Crane J. Reducing asthma mortality with the asthma self-management plan system of care. Am J Respir Crit Care Med 2001;163:3–4.
ARTICLE IN PRESS Management of Asthma in Spain
8. Cerveri I, Zoia MC, Bugiani M, et al. Inadequate antiasthma drug use in the north of Italy. Eur Respir J 1997;10:2761–5. 9. Lagerlov P, Veninga CCM, Muskova M, et al. Asthma management in five European countries: doctors’ knowledge, attitudes and prescribing behaviour. Drug Education Project (DEP) group. Eur Respir J 2000;15:25–9. 10. Rickard KA, Stempel DA. Asthma survey demonstrates that the goals of the NHLBI have not been accomplished. J Allergy Clin Immunol 1999;103:s171. 11. Cimas JE, Arce MC, Gonza! lez ME, Lo! pez Vin* a A. Atencio! n especializada y atencio! n primaria en el tratamiento del asma: ‘‘existen diferencias’’. Aten Primaria 1997;19: 477–81. 12. Weiss KB, Gergen PJ, Hodgsen TA. An economic evaluation of asthma in the United States. N Engl J Med 1992;326:862–6. 13. Vollmer WM, O‘Hallaren M, Ettinger KM, et al. Speciality differences in the management of asthma. A cross-sectional assessment of allergists’ patients and generalists patients in a large HMO. Arch Intern Med 1997;157:1201–8. 14. Abdulwadud OA, Abramsen MJ, Ligth L, Thien FCK, Walters EH. Comparison of patients with asthma managed in general practice and in a hospital clinic. Med J Aust 1999;171:72–5. * 15. Sociedad Espanola de Neumologia y Cirugia Tora! cica y * Sociedad Espanola de Medicina Familiar y Comunitaria. Recomendaciones para la atencio! n del paciente con asma. Arch Bronconeumol 1998;34:394–9.
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16. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. NHLBI/WHO Workshop Report, National Institutes of Health, National Heart, Lung and Blood Institute, NIH Publication Number 95-3659, 1995. 17. Rabe KF, Vermiere PA, Soriano JB, Maier WC. Clinical management of asthma in 1999: the Asthma Insights and Reality in Europe (AIRE) study. Eur Respir J 2000;16: 802–7. 18. Walsh LJ, Wong CA, Cooper S, Guhan AR, Pringle M, Tattersfield AE. Morbidity from asthma in relation to regular treatment: a community based study. Thorax 1999;54:296– 300. * A. Estudio de 19. Cimas JE, Arce MC, Gonza! lez ME, Lo! pez Vina factores relacionados con la morbilidad del asma. Arch Bronconeumol 1997;33:389–94. 20. Horn CR, Cochrane GM. An audit of morbidity associated with chronic asthma in general practice. Respir Med 1989;83:71–5. 21. Martinez-Moratalla J, Almar E, Sunyer J, et al. Estudio Europeo del Asma. Identificacio! n y tratamiento de individuos con criterios epidemiolo! gicos de asma en adultos * jo! venes de cinco a! reas espanolas. Arch Bronconeumol 1999;35:223–8. 22. Crombie IK, Wright A, Irvine L, Clark RA, Slane PW. Does passive smoking increase the frequency of health service contacts in children with asthma. Thorax 2001;56:9–12.
A comparison of primary care physicians and pneumologists in the management of asthma in Spain: ASES study ! * a,*, J. Enrique Cimasb, Concepcio! n D!ıaz Sa! nchezc, Antolin Lopez-Vi na Gemma Coriad, Onofre Vegazoe, Cesar Picado Vallesfon behalf of Scientific Committee of ASES study Servicio de Neumolog!ıa, Cl!ınica Puerta de Hierro, C/San Martin de Porre! s, 4, Madrid 28035, Spain ! 33210, Spain Primary Health Care Center of Contrueces, C/Rio Cares s/n, Gijon c * * s/n, Gijo! n 33394, Spain Servicio de Neumolog!ıa, Hospital de Cabuenes, C/Cabuenes d Primary Health Care Center of La Calzada, C/Oriental 11, Gijo! n 33212, Spain e Medical Department, AstraZeneca Farmace! utica Spain, S.A., C/Serrano Galvache, 56, Madrid 28033, Spain f Servicio de Neumolog!ıa, Hospital Clinic, C/Villarroel, 170, Barcelona 08036, Spain a
b
KEYWORDS Asthma; Management; Epidemiology; Pneumologists; Primary care; Spain
Summary The purpose of the ASES study is to determine the clinical characteristics of Spanish asthmatic patients seen in primary care (PC) and in pneumology (P) departments, comparing the availability of diagnostic methods, morbidity, the type of treatment and follow-up between the two health care settings. ASES is a multicenter, descriptive, cross-sectional study. The physicians were selected by random sampling. The data were collected by the participating physicians using three questionnaires. Data were collected on 2349 asthmatic patients (1298 from hospitals and 1051 from PC). Smokers predominated in the PC setting (P ¼ 0:000). The spirometry was performed at least once a year in 87.2% of the patients seen in P and 39.8% in PC (P ¼ 0:000). Morbidity was high in both groups (P and PC), more than two nighttime awakenings per month (25.5% versus 29%) and emergency visits in previous year (26% versus 21%). A high percent of asthmatic patients was using both inhaled corticoids and long-acting b2 -agonists (49.5% versus 32%). The 30% of PC patients could not be classified into any step of the treatment. In Spain, the morbidity of disease is high, despite the large use of drugs. Objective monitoring tests have very limited use in PC. r 2003 Elsevier Science Ltd. All rights reserved.
Introduction An increase in asthma prevalence not attributable to improved diagnostic methods has been seen in many countries all over the world in recent *Corresponding author. Tel.: +34-913162240; fax: +34-913730535. * E-mail address: [email protected] (A. Lo! pez-Vina).
years.1,2 At the same time, a high morbidity has been detected which may be attributed, at least in part, to deficient patient medical care.3,4 Asthma is a potentially fatal disease,5 but most deaths could be avoided with preventive measures, particularly self-treatment protocols.6,7 Various studies indicate that asthmatics are inadequately treated in many countries.3,8–10 In order to improve medical care to asthma patients,
0954-6111/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0954-6111(03)00041-6
ARTICLE IN PRESS Management of Asthma in Spain
knowledge should be obtained of the situation of asthma in the setting where improvements are contemplated, identifying the diagnostic methods used, the control of the disease, and the characteristics of treatment and of the follow-up measures applied in routine clinical practice. Most asthmatic patients are treated by primary care (PC) physicians, both in Spain and elsewhere. The rest of patients are seen by specialists in pneumology (P), and only a small percentage are managed by other specialists (allergologists, internists).11,12 Some studies have found differences in the care of asthmatics by PC physicians or ‘‘specialists’’.13,14 These differences have been attributed to the time dedicated to the patients and to professional knowledge. It would therefore be desirable to know the differences between these two groups of physicians in Spain, with the aim of improving coordination between them in the care of asthmatic patients. One of the main problems for assessing adequate professional care is the lack of specific and universally accepted guidelines. In the case of asthma, national15 and international16 consensus, guidelines are available as a reference for all health care professionals involved in the management of asthmatic patients. The aim of our study is to determine the characteristics and clinical status of Spanish asthmatics seen in the PC and P settings, and to ascertain the existing differences in the availability of diagnostic methods, the morbidity rate, the type of treatment and the monitoring between the two health care settings.
Material and methods This is a multicenter, descriptive, cross-sectional study to collect data on the characteristics of asthmatic patients seen at PC offices and hospital P outpatient clinics throughout Spain. The ASES study was coordinated by a Scientific Committee composed of an Asthma Area delegate from the Spanish Society of Pneumology and Chest Surgery (Sociedad * Espanola de Neumolog!ıa y Cirug!ıa Tora! cica, SEPAR) and another from the Respiratory Group in Primary Care (Grupo de Respiratorio en Atencio! n Primaria, GRAP). In order to avoid seasonal bias, data on asthmatics were collected during two 4-month periods from October 1, 1998 to January 31, 1999 and from March 1, 1999 to June 30, 1999, respectively. PC physicians were selected by stratified random sampling in proportion to the regional population.
873
To this effect, the Spanish territory was divided into five areas, excluding the non-mainland areas of the Canary Islands, the Balearic Islands, Ceuta and Melilla for logistical reasons. Pneumologists were selected by random block samplingFthe sampling unit in this case being the Department of Pneumology rather than the individual physician. A list was prepared by Autonomous Communities, selecting only those Departments of Pneumology belonging to hospitals ascribed to the public health care system (Table 1). All selected physicians were requested by mail to agree to participation in the study. Those who failed to give agreement were excluded, as were those whose occupational characteristics precluded adequate collaboration during the study (emergency care physicians and/or reinforcements, substitutions and physicians pending transfer). The excluded physicians were systematically replaced by the individual immediately following on the randomization list. The required sample size for maximum indetermination of the test parameters (p ¼ q ¼ 0:5), with a 95% confidence interval (CI) and a precision of 3%, was 1608 patients per study period, assuming 20% potential losses. The 134 PC physicians selected were required to collect information on 12 asthmatics systematically selected during the 4 months of each period (the first three patients attending each month for consultation concerning any aspect related to asthma, including prescriptions, etc.). Physicians who voluntarily withdrew during the study or who failed to respond or submit any data were not replaced and were regarded as non-responses. Fifty-eight Departments of Pneumology were selected, nine of which were divided into two units based on the population they covered, thus yielding a final total of 67 units. Each unit was requested to collect data from 15 patients systematically selected during the 4 months of each of the two periods, in a way similar to PC. Three questionnaires were prepared and sent to the selected PC and P physicians. One questionnaire was intended to record data concerning the organization and infrastructure at the different centres (location, population seen, availability of diagnostic means), and was completed by each professional once at the start of each period. Another questionnaire was designed to calculate the prevalence of asthma in the population seen (visits for asthma compared to the total visits during the study period), and was completed by the physician at the end of each period. Finally, the third questionnaire recorded the sociodemographic, diagnostic, morbidity and treatment data
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Population of Autonomous Communities. Population figures as of January 1, 1998, obtained from the corresponding municipal census statistics declared official by the Government authorities (Royal Decree 950/2001 of August 3).
18 17 17 8 7 67 37 34 33 15 15 134 27 25 25 11 11 100 10 382 728 9 558 800 9 418 787 4 339 626 4 096 440 37 796 381 Area Area Area Area Area
I II III IV V
* and Comunidad Valenciana Cataluna Extremadura, Andaluc!ıa and Murcia ! Madrid, Castilla-La Mancha and Castilla-Leon Galicia, Asturias and Cantabria ! Pa!ıs Vasco, Navarra, La Rioja and Aragon Total
% Regions
Population (no. of inhabitants)
Primary care physicians
Pneumology units
A. Lo ´pez-Vin ˜a et al.
Table 1 Proportional distribution of primary care physicians and pneumologists according to the population in each of the five geographic areas established.
874
of each patient studied, and was completed by the physician during the interview with each asthmatic. This last questionnaire also documented the patient spirometric and/or peak expiratory flow (PEF) values obtained on the day of the interview. The three questionnaires were subjected to pilot evaluation before the start of the study using 10 physicians pertaining to the health care area of ! (Asturias). Following this pilot period, some Gijon changes were made in the questionnaires in order to improve comprehensibility. If no response had been received 2 weeks after the deadline, the participants were contacted by telephone in an attempt to obtain the required information. Four months after the end of the last study period (i.e., October 31, 1999), data collection was definitively closed. A descriptive statistical analysis was made using means and standard deviations (SD) for the quantitative variables and proportions for the qualitative variables. For comparing the data from the PC and P settings, Student’s t-test was used for the quantitative variables, and a Z-test to compare proportions for the qualitative variables. The 95% CI were calculated in all cases. Bilateral statistical significance was considered for P ¼ 0:05 in all analyses. SPSS version 9.0 for Windows, Primer statistics 1.0, and CIA (Confidence Interval Analysis) 1.0 were used for statistical processing.
Results Of the selected samples, a total of 106 PC physicians started participation in the ASES study; 34 of these withdrew before the end of the studyFthe response rate therefore being 58% (n ¼ 72). As regards the P units, 79% responded (n ¼ 53). The potential differences between the physicians who completed both study periods and those who withdrew before completion were analyzed, and no significant differences were found in terms of age, sex, specialty, population size or geographic area. Data from 2349 asthmatic patients were collected (1051 in PC and 1298 in the P setting). The mean age was 46721 years in PC and 46719 years in P. There were significantly more smokers in PC than in P (P ¼ 0:000). The rest of the differences are shown in Table 2. The proportion of consultations for asthma with respect to total consultations was 32% in P and 4% in PC. Spirometry was performed at the time of consultation in 80% of the hospitals, while only 50% of the PC physicians had access to this
ARTICLE IN PRESS Management of Asthma in Spain
Table 2
875
Sociodemographic characteristics of the asthmatic patients in both groups. Hospital
Age Sex Males Females Smoking Non-smoker Exsmoker Smoker Occupational status Unemployed Housewife Student Active Retired Early retirement
Primary care
P
No.
% (CI 95%)
No.
% (CI 95%)
1298
46 (44,6–47,1)
1051
46(44,6–46-,8)
NS
477 821
37 (34.1–39.4) 63 (60.6–65.9)
453 598
43 (40.1–46.1) 57 (53.9–59.9)
NS NS
946 251 101
73 (70.5–75.3) 19 (17.2–21.5) 8 (6.3–9.3)
691 181 179
66 (62.9–68.6) 17 (14.9–19.5) 17 (14.8–19.3)
0.0001 NS 0.0000
57 417 207 422 179 16
4 (3.3–5.6) 32 (29.6–34.7) 16 (14–17.9) 32.5 (30–35.1) 14 (11.9–15.7) 1 (0.7–2)
42 290 205 290 204 20
4 (2.9–5.3) 28 (24.9–30.3) 19.5 (17.1–21.9) 28 (24.9–30.3) 19 (17–21.8) 2 (1.1–2.9)
NS 0.01 0.02 0.01 0.0002 NS
diagnostic method. Among the latter, 25% could request spirometry directly from their specialized reference center, while the rest had no choice but to refer the patients elsewhere. On the other hand, 87% (CI: 85.4–89.0) of the patients seen in P were subjected to spirometry at least once a year, while spirometry was not performed at any time in only 3% (CI: 2.2–4.2). In PC, spirometry was carried out at least once a year in only 40% of the patients (CI: 36.8–42.7), and never in 23% (CI: 20.6–25.7). These differences were statistically significant (P ¼ 0:000). On the day of the interview, spirometry data were recorded in 1168 patients seen in P (90%; CI: 88.4–91.6), and PEF data in 898 (69%; CI: 66.7– 71.7). By contrast, in the PC setting, spirometric data were recorded in 341 patients (32%; CI: 29.6– 35.3), and PEF data in 159 (15%; CI: 13.0–17.3) (P ¼ 0:000). The spirometric values recorded were similar in both groups of patients. Thus, an FEV1 of over 80% of the theoretical value was recorded in 58% (CI: 55–60.7) of the P group and in 52% (CI: 46.3–56.9) of the PC group. In turn, an FEV1 of under 60% of the theoretical value was recorded in 18% (CI: 16.1–20.5) of the patients seen in P and in 21% (CI: 16.8–25.4) of those seen in PC. Finally, 24% (CI: 21.4–26.2) of the P group and 27% (CI: 22.5–32) of the PC group yielded FEV1 values between 60% and 80% of the theoretical value. The morbidity of asthmatic patients was high in both groups. It should be stressed that the P group
showed a greater number of visits to the emergency department, hospital admissions and admissions to intensive care units than the PC group. By contrast, the latter showed more work and school absenteeism and made greater daily use of short-acting b2 agonists (Table 3). Differences between the two groups were recorded in the type of medication used to treat asthma (Table 4). Thus, 90% (CI: 88–91.3) of the patients seen in P used inhaled corticoids versus 62.5% (CI: 59.6–65.4) of those seen in PC (P ¼ 0:000); budesonide was the most widely used drug in both groups. The P group also used significantly more long-acting b2 -agonists (56%, CI: 53.8–59.2) than the PC group (44%; CI: 41.2–47.2), as well as more short-acting b2 agonists (92%; CI: 90–93.1 versus 81.6%, CI: 79.3–84) (P ¼ 0:000 for both). However, other drugs were more widely used in PC (antihista= mines, nedocromil, ipratropium bromide and immunotherapy) (Po0:05). When grouped by associations and recommended doses, the PC group was seen to use fewer high-dose inhaled corticoids and in combination with long-acting b2 -agonists, and more non-classifiable treatments were administered (mucolytic agents, antitussive drugs) (Table 5). Some particularities were seen. Thus, 0.8% (CI: 0.3–1.4) of the patients seen in P used inhaled corticoids as needed, but this figure increased to 3% (CI: 1.9–4) in the PC group. By contrast, 26% (CI: 23–28.3) of the asthmatics seen in PC have been
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Table 3
A. Lo ´pez-Vin ˜a et al.
Morbidity data in each group of asthmatic patients.
Symptoms more than once a week More than two nighttime awakenings a month Work or school absenteeism Emergency visits in previous year Hospital admission in previous year Ever admitted to intensive care unit Daily use of short-acting b2 -agonists Oral corticoid cycles in the past 6 months
Hospital
Primary care
No.
% (CI 95%)
No.
% (CI 95%)
411 331 207 339 172 84 155 273
32 (29.1–34.2) 25.5 (23.1–27.9) 16 (14–17.9) 26 (23.7–28.5) 13 (11.4–15.1) 6.5 (5.1–7.9) 12 (10.2–13.7) 21 (18.8–23.2)
253 304 229 222 100 31 190 227
24 (21.5–26.7) 29 (26.2–31.7) 22 (19.3–24.3) 21 (18.7–23.6) 9.5 (7.8–11.5) 3 (2–4.1) 18 (15.8–20.4) 22 (19.1–24.1)
prescribed a short-acting b2 -agonist, as compared to only 2% (CI: 1.2–2.8) in the P group. Long-acting b2 -agonists were used without inhaled corticoids in 1% (CI: 0.5–1.8) of the patients seen in P and in 11% (CI: 8.7–12.4) of those seen in PC. In turn, 2% (CI: 1–2.6) of the PC group used long-acting b2 -agonists as needed, this figure dropping to 0.5% (CI: 0.1–1.1) in the P setting. It should also be mentioned that 3% (CI: 2.3–4.6) of the PC group (n ¼ 35) received theophylline as the only treatment, while this only occurred in two patients from the P group (0.1%; CI: 0.01–0.5). As regards other treatment measures, 75.5% (CI: 73.2–77.8) of the patients seen in P were given information on environmental measures to prevent asthma attacks, while this proportion increased to 81% (CI: 78.3–83.1) in PC. Likewise, written selftreatment plans were distributed among the patients in both health care settings: 66% (CI: 63.2–68.4) in the P group and 61.5% (CI: 58.5–64.4) in PC. By contrast, daily PEF measurements in the home were made by 25% (CI: 23–27.7) of the P patients versus only 5% (CI: 3.6–6.3) of those seen in PC (P ¼ 0:000).
Discussion This study addresses some aspects of asthma management in Spain from the perspective of the physician, and shows an inadequate use of objective measures for patient monitoring, a high morbidity and a high proportion of inadequate treatments. One limitation of the study is the high percentage (42%) of PC physicians who failed to respond, though this fact probably has little influence upon the results obtained, since no differences were
P
0.000 0.072 0.000 0.005 0.005 0.000 0.000 0.762
seen between the physicians who responded and those who did not. Other limitations are inherent to the crosssectional study design, using the medical diagnosis of asthma and therefore not including patients not diagnosed or those who do not visit the doctor. Thus, the results refer only to the clinical care of patients diagnosed of asthma who regularly visit their physician (consulting population). It has not been possible to take into account the severity of asthmatic patients as it was not possible to classify them according to clinical and functional criteria given that most of them were on treatment. Therefore, the comparison between both populations (PC and P) has this constraint; although it is important, we considered it to be of little relevance to the objective of the study which was to describe the situation in each one the health care settings. One of the most striking findings of the study is the scant use made in the PC setting of objective measures to monitor asthmatic patients. Thus, spirometry is never performed to one-quarter of asthmatic patients, while in 60% of the cases spirometry is never done or is performed less than once a year. These observations contrast with the recommendations of the guidelines for asthma treatment,15,16 where emphasis is placed on the significance of assessing pulmonary function in the monitoring of asthmatic patients. Such functional assessment is advised at least once a year, and ideally whenever the patient is seen. The PEF meter can replace spirometry when the latter is not available, but this simple and inexpensive device is used even less than spirometry. One of the aims of treatment is to achieve a pulmonary function that is normal or as normal as possible. However, this objective is difficult to achieve if pulmonary function is not even tested. It
92 87
87 42 45
38
Other bronchodilators Theophylline Ipratropium bromide
Oral corticoids Total Prednisone Deflazacort
Other drugs Total
226
733 432 301
Long-acting b2 -agonists Total Salmeterol Formoterol
Immunotherapy at any time Total
1189
2 21 117 19
1164 56 814 294
Short-acting b2 -agonists Total
Other antiinflammatory agents Cromoglycate Nedocromil Antileukotrienes Antihistamines
Inhaled corticoids Total Beclomethasone Budesonide Fluticasone
17 (15.3–19.5)
3 (2–4)
7 (5.4–8.2) 3 (2.3–4.3) 3.5 (2.5–4.6)
7 (5.7–8.6) 7 (5.4–8.2)
56.5 (53.8–59.2) 33 (30.7–35.8) 23 (20.9–25.5)
92 (90–93.1)
0.1 (0.01–0.5) 2 (1–2.4) 9 (7.5–10.7) 1.5 (0.8–2.2)
90 (88–91.3) 4 (3.2–5.5) 63 (60.1–65.3) 23 (20.4–24.9)
253
114
42 5 37
99 99
465 342 123
858
5 36 67 121
657 99 440 118
No.
No.
% (CI 95%)
Primary care
Hospital
Table 4 Drugs used for the treatment of asthmatic patients.
24 (21.5–26.7)
11 (8.9–12.7)
4 (2.9–5.3) 0.5 (0.1–1.1) 3.5 (2.5–4.8)
9 (7.7–11.3) 9 (7.7–11.3)
44 (41.2–47.2) 32.5 (29.7–35.4) 12 (9.7–13.6)
82 (79.3–84)
0.5 (0.1–1.1) 3 (2.4–4.7) 6 (4.9–8) 11.5 (9.5–13.4)
62.5 (59.6–65.4) 9 (7.7–11.3) 42 (38.9–44.8) 11 (9.3–13.1)
% (CI 95%)
0.000
0.000
0.006 0.000 0.910
0.051 0.020
0.000 0.714 0.000
0.000
0.152 0.007 0.024 0.000
0.000 0.000 0.000 0.000
P
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Management of Asthma in Spain 877
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Table 5
A. Lo ´pez-Vin ˜a et al.
Type of treatment used in each group of asthmatic patients.
No treatment Only short-acting b2 -agonists as needed Low-dose inhaled corticosteroidsa High-dose inhaled corticosteroidsb Inhaled corticosteroids+long-acting b2 -agonists Oral corticosteroids Non-classifiable a
Hospital
Primary care
No
% (CI 95%)
No
% (CI 95%)
4 87 174 227 643 88 75
0.3 (0.07–0.7) 7 (5.4–8.2) 13(11.6–15.3) 17 (15.4–19.6) 49.5 (46.8–52.3) 7 (5.4–8.2) 6 (4.5–7.1)
17 113 133 92 335 42 319
2 (0.9–2.5) 11 (8.8–12.6) 13 (10.6–14.7) 9 (7.1–10.6) 32 (29.1–34.7) 4 (2.9–5.3) 30 (27.6–33.1)
P
0.002 0.000 0.661 0.000 0.000 0.006 0.000
Low-dose inhaled corticosteroidsp500 mg/day of beclomethasone or budesonidep250 mg/day of fluticasone. High-dose inhaled corticosteroidsX500 mg/day of beclomethasone or budesonideX250 mg/day of fluticasone.
b
could be thought that the reason for this is a lack of spirometers and PEF meters, but the reason is more likely to be that physicians are unaware of their importance or simply consider them of little value, since access at least to a PEF meter is usually easy and cheap. In the P units the situation is different, since only 3.2% of the patients were never subjected to spirometry, and over 80% were evaluated by this technique at least once a year. This lack of use of pulmonary function test agrees with the Spanish data of the AIRE study,17 where 65% of all patients reported never having been subjected to spirometry, and an additional 26% said that no such study had been made on them in the previous year. These figures are higher than the European averages. Therefore, from the patient perspective (the AIRE data were collected from the patients), the problem is even worse. It is most probable that the patients seen in P are more severe than the patients seen in PC as the indirect data (greater number of visits to the emergency room and of hospitalizations as well as a greater number of patients receiving treatment with high doses of corticosteroids and these in combination with long-lasting b2 -agonists) are indicative of this. In any case as in other studies, patient morbidity was high17,18 in both the PC and P setting. More than 25% of the asthmatics woke up at night two or more times a month, while 19% missed work or school, 24% visited the emergency department in the previous year, and 12% were admitted to hospital in the previous year because of asthma. One of the reasons for poor asthma control is prescription of inadequate treatment,19,20 though this does not seem to have been the main cause in our study, at least in the population seen in the P units (90% were receiving inhaled corticoids, and 94% could be classified on some severity stage). Inadequate treatment could have been the cause of high morbidity in only 30% of patients seen in PC
who could not be classified in any severity stage, but in the remaining 70% inadequate therapy does not seem to be the main cause either. Inadequate monitoring of therapeutic objectives and poor treatment compliance could be the reasons for this discrepancy between morbidity and treatment. In the AIRE study,17 only 15% of the patients were receiving inhaled corticoids. The difference between what the physicians claim to be prescribing and what the patients claim to be receiving is too great, and suggests that poor patient compliance is one of the causes of high morbidity. An interesting finding is the existence among the asthmatics seen in PC of more than twice as many smokers as in P. These data are similar to those found in two studies conducted in Australia and the United States,13,14 but which the authors overlook. One reason could be that hospitals deal with the more serious asthma cases, who do not smoke because of the severity of their disease (the percentage of former smokers is similar), but another possible explanation is that PC physicians and the smoking asthmatics themselves attribute the symptoms to smoking and consequently request less hospital intervention. In the European study,21 smoker status was strongly associated with nonacknowledgement of the disease, thus suggesting that the symptoms are attributed to smoking, as a result of which the patient does not report to the doctor. Even after diagnosis, the patients at least partially continue to blame the symptoms on smoking. One study has shown that asthmatic children with smoking parents are not adequately treated22 because the parents tend to take them less to see the doctor. Taken together, all these data suggest that tobacco smoking appears to lead to deficient management of asthmatic patients, the responsibility for this situation possibly being distributed among the parents, patients and physicians. Medical professionals should take this aspect
ARTICLE IN PRESS Management of Asthma in Spain
into account, retaining asthma control as the primary treatment aim even if the patient smokes. PEF monitoring is recommended for the followup of asthmatic patients.15,16 In this study, only one-fifth of the asthmatics seen in PC used the PEF meter at home, as compared to 25% of those seen in the P setting. Both proportions are very low. Surprisingly, the physicians claim that most patients have received self-treatment instructions. This data agree with those of the AIRE study, according to which Spain is the participating European country with the largest percentage of patients with self-treatment plans. We have no explanation for this finding, but an erroneous understanding of what is meant by a self-treatment plan may be responsible, together with the misconception that b2 -agonist rescue medication constitutes such a plan. The low proportion of patients with PEF monitoring suggests that in fact few self-treatment plans contemplate increased inhaled corticoids or the use of oral corticoids under certain circumstances. Such plans are the ones actually having an impact upon asthma morbidity and mortality.6 The differences between PC and P in the way the pulmonary function test was used may reflect differences the working conditions (less time available per patient, less spirometers) and the fact that there is less specific training in PC. To improve this situation a better cooperation would be necessary between the two health care settings as well as the development of ongoing training programmes in PC. To summarize, objective methods used are very little in PC for the monitoring of asthmatic patients. Morbidity associated with the disease is very high both in the PC and P setting, possibly due to inadequate monitoring of therapeutic objectives by health professionals and to poor patient compliance with treatment, due to a lack of educational strategies for improving patient adhesion. The improved care of asthmatic patients in Spain therefore requires an increased use of objective monitoring tests in PC (i.e., spirometers and PEF meters). Moreover, in both PC and P, emphasis should be placed on the need to monitor the established therapeutic objectives and the convenience of implementing patient education programs to afford increased patient autonomy and better treatment compliance.
Acknowledgements The authors acknowledge the effort of all investigators participating in the ASES study, and thank
879 ! ASTRAZENECA Farmaceutica Spain, S.A., which financed the logistic aspects of the study and granted two scholarships for a pneumologist (Dr ! D!ıaz) and a primary care physician (Dr Concepcion Gemma Coria), who centralized data reception and tabulation.
Appendix A. Pneumologists participating in the ASES study Concha Pellicer, Hospital Francesc de Borja (Gand! Aguero, ! de Valdecilla !ıa); Ramon . Hospital Marques (Cantabria); Jose! Ma Ignacio Garc!ıa, Hospital General Serran!ıa (Ronda); Santiago Bardaji Hospital Sant Jaume (Mataro! ); Luis Border!ıas, Hospital San ! Jorge (Huesca); Luis Perez del Llano, Hospital Xeral (Lugo); Ma Jose! Linares, Hospital Virgen de las * Nieves (Granada); Jose! Luis Viejo Banuelos, Hospi. (Burgos); Eduardo Garc!ıa Pacho! n, tal General Yague ! Hospital Vega Baja (Orihuela); Manuel Perez de las Casas, Hospital de Navarra; Celso Alvarez Alvarez, Hospital Instituto Nacional de Silicosis (Asturias); * de Federico Manresa, Hospital Pr!ıncipes de Espana Bellvitge (Barcelona); Inmaculada Alfageme, Hospital de Valme (Sevilla); Rafael Vah!ı Maqueda, Hospital Osuna (Sevilla); Luis Marco Jorda! n, Hospi! tal de Guipuzcoa; Carmen Montero Mart!ınez, ! * Hospital Juan Canalejo (La Coruna); Antol!ın Lopez * * Vina, Hospital Cabuenes (Asturias); Alfredo de Diego, Hospital La Fe (Valencia); Carlos Villasante, Hospital La Paz (Madrid); Agust!ın Sojo Gonza! lez, Hospital San Pedro de Alca! ntara (Ca! ceres); Aurelio Valencia, Hospital Carlos Haya (Ma! laga); Ignacio Ma Sa! nchez, Hospital General (Guadalajara); Javier Tamayo, Ambulatorio del Hospital Ramo! n y Cajal (Madrid); Joan Serra Batlles, Hospital General de Vic (Barcelona); Manel Rubio Godoy, Hospital Josep Trueta (Girona); Rosa Sa! nchez Gil, Hospital Virgen del Roc!ıo (Sevilla); Fernando Fuentes Otero, Hospital Infanta Cristina (Badajoz); Salvador Herna! ndez Flix, Hospital Sant Joan (Reus); Xavier Aguilar, Hospital Joan XXIII (Tarragona); Jose! Luis AlvarezSala Walker, Hospital Cl!ınico (Madrid); Julio Ancochea, Hospital La Princesa (Madrid); Ma Jose! Ferreiro, Hospital Puerta de Hierro (Madrid); Juan Guallar Ballester Hospital La Magdalena (Castell! on); Patricia Lloberes, Hospital Valle d’Hebro! n (Barcelona); Jose! Luis Carretero Sastre, Hospital R!ıo Ortega (Valladolid); Ma Angeles Ferandez Jorge, Hospital R!ıo Carrio! n (Palencia); Nicola! s Gonza! lez Mangado, Hospital Concepcio! n (Madrid); Pedro Mart!ın Escribano, Hospital Doce de Octubre
ARTICLE IN PRESS 880 ! Martinez-Moratalla Rovira, Hospital (Madrid); Jesus ! Hospital General (Albacete); Cesar Picado, Hospital Clinic (Barcelona); Vicente Plaza, Hospital Santa Creu i Sant Pau (Barcelona); Eusebi Chiner, * Hospital San Juan (Alicante); Luis Pineiro Amigo, Hospital Xeral Cies (Pontevedra); Juan Ga! ldiz, Hospital Cruces (Vizcaya); Joaqu!ın Lamela, Hospital * (Orense). Cristal-Pinor
Primary care physicians participating in the ASES study Blas Cloquell Rodrigo, C.S. Florida (Alicante); Ma Angeles Cabrera Ferriols, C.S. Hospital Provincial Alicante; Ramon Anto! n Torres, C.S. Crevillent; * Ernesto Vines Martinez, C.S. Petrer; Margarita Ayala Rullan, C.S. Javea (Xabia); Karlos Naberan * C.S. Clot (Barcelona); Angel Cano Romero, Tona, C.S. Bon Pastor (Barcelona); Eva Tarrats Feliu, C.S. Creu Alta (Sabadell); Jose Antonio Dom!ınguez del Rio Ambulatorio Vilafranca del Penedes; Francisco Cebrian Montolio, C.S. 9 de Octubre (Castello! n); Remei Girona Bastus, C.S. Dr. Vilaplana-Taila (Girona); Susana Sarriegui Dominguez, C.S. La Bordeta (Lleida); Ma Antonia Navarro Echeverria, C.S. Borges Blanques; Roland Juan Franquet, C.S. Sant Carles de la Rapita; Carmen Mas Tomas, C.S. Economista Gay Valencia; Elisa Flecha FernandezCouto, C.S. Trinitat (Valencia); Tomas Paga Bueso, C.S. Trinitat (Valencia); Carlos Bonora Xerri, C.S. Concordia (Burjasot); Juan Luis Castillo Lopez, C.S. Anexo II (Badajoz); Augusta Albarran Sanz-Calcedo, C.S. Pueblo Nuevo del Guadiana; Maria Soledad Iglesias Campos, C.S. Zafra I; Purificacion Herrera Valdes, C.S. Nicola! s Perez Jimenez (Cabeza del Buey); Manuel Prieto Oliva, C.S. Hervas; Jose Antonio Rodr!ıguez Iglesias, C.S. Algeciras-Norte; Juan Candau Camacho, C.S. San Telmo (Jerez de la Frontera); Emilio Sa! nchez Caballero, C.S. Baena; Ma Rosa Palomar Alguacil, C.S. de Lucena; Salvador Mart!ınez Puentedura, C.S. Motril Centro; Encarna * Luis Antonio Ferna! ndez Diaz Diaz, C.S. Salobrena; Saura, C.S. Ronda-Norte; Natividad Ferna! ndez Perea, C.S. de Mula; Antonio Matias Urrea Andreu, C.S. San Vicente (Cartagena); Juan Fco. Menarguez Puche, C.S. Molina de S; Francisco Belda Marhuenda, C.S. Archena/Cons.Villanueva (Archena/Villanueva del Segura); Francisca Matilde Lopez Lara, C.S. Alcala! Guadaira; Pedro Ros Sanchez Cruzado, C.S. Torreon (Ciudad Real); Ramzi Jamil Ala, C.S. Daimie-I; Laureano Go! mez Gonzalez, C.S. Campo * Castrillo San Jose, C.S. de Criptana; Begona Benavides de Orbigo; Andres Castillejo Alvarez, C.S. Canillas-Prosperidad (Madrid); Margarita Gonz-
A. Lo ´pez-Vin ˜a et al. a! lez Polo, C.S. Hermanos Miralles (Madrid); Esther Picazo Gomez, C.S. los Almendrales (Madrid); Isabel Garc!ıa Lazaro, C.S. Ciudad de los Periodistas ! (Madrid); Pilar Gomez Perez, C.S. Pa! rroco Julio * Morate (Madrid); Ana Pastor Rodriguez Monino, C.S. Juan de Vera (Madrid); Olvido la Torre Rodriguez, C.S. Pinto; Silvia Kieckebwsch Kuserow, C.S. Fron! Moreno, teras (Torrejon de Ardoz); Ma Jose Alvarez C.S. Dr. Granero (Alcorcon); Almudena Paredes Garcia, C.S. Jardinillos (Palencia); Jose Antonio Iglesias Valiente, C.S. Alamedilla (Salamanca); Juan Manuel de Andres Rubio, C.S. Sepulveda; Isabel Perez Ortega, C.S. Almazan; Jose! Luis Turabian Ferna! ndez, C.S. Benquerencia-Poligono (Toledo); Mercedes Redondo Valdeolmillos, C.S. Magdalena (Valladolid); Ana Carvajal de la Torre, C.S. Federico * Tapia (La Coruna); Maelba Veleiro Fernandez, C.S. Vilalba; Miguel Angel Lo! pez Ortiz, C.S. Ponte (Orense); Celia Rodr!ıguez Perez, C.S. Ponte (Orense); Ernesto Mart!ınez Estrada, C.S. La Calzada ! (Gijon); Arturo de la Vega Cuyas, C.S. La Magdalena (Aviles); Tomas Gutierrez Renedo, C.S. Villalegre (Aviles); Froilan Gutierrez de Diego, C.S. Lugones (Lugones); Victoria Sa! nchez Ventin, C.S. Beiramar (Vigo); Julia Bo! veda Fontan, C.S. Pintor Colmeiro (Vigo); Maria Carmen Perez del Oso, C.S. Polanco; Roman Ganzara!ın Gorosabel, C.S. Ibarra; Luis * Ferna! ndez Urzainqui, C.S. Baranain; Jose! Antonio Iruretagoyena Amiano, C.S. de Elizondo; Leonor Aurrekoetxea Bildosola, C.S. Santutxu (Bbilbao); * Victoria Astobiza Arino, C.S. Zurbaran (Bilbao); Roberto Gonza! lez Guerra, C.S. Kueto Sestao; Ma Luisa Gutierrez Ibarzabal, C.S. Leioa.
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