Actualización de la Estrategia en EPOC del Sistema Nacional de Salud

Objectives

Spain’s National Health System strategy for chronic obstructive pulmonary disease (COPD) was approved in 2009 and updated after an evaluation completed in March 2013.[1]It seeks to improve the effectiveness, quality and efficiency of COPD prevention, diagnosis, treatment and support by incorporating scientific evidence, organisational developments and lessons from implementation.[2]Its six strategic areas are prevention and early detection, chronic-patient care, exacerbation care, palliative care, professional training and research.[1]

• Reduce COPD incidence by lowering tobacco use, strengthening enforcement of tobacco-control legislation, addressing environmental and occupational exposures, improving public and professional awareness, and providing smoking-cessation programmes through health centres.[3]National targets sought to reduce current smoking prevalence among people aged over 15 and tobacco use among those aged 15 to 24 to 25% by 2016.[3]
• Improve early diagnosis by ensuring appropriate structural, material and organisational resources in health centres and undertaking targeted spirometry with bronchodilator testing for symptomatic people aged over 40 with substantial current or previous tobacco exposure.[3][4]Ensure that forced spirometry is accessible and meets defined quality standards.[4]
• Reduce COPD morbidity and mortality and improve health-related quality of life through multidimensional assessment, nursing care plans from diagnosis, smoking-cessation support, appropriate pharmacological treatment, home oxygen and other respiratory therapies, and structured respiratory rehabilitation.[4][5]
• Improve the appropriate use of home oxygen therapy by confirming clinical indication, addressing smoking and hypoxaemia, and supporting use for more than 15 hours daily where indicated.[6]Support mobility through home-based respiratory therapies and provide rehabilitation in both primary and specialised care.[5]
• Provide evidence-based management of COPD exacerbations, reduce avoidable emergency visits and unplanned readmissions within 30 days of discharge, and strengthen continuity between hospital, primary and specialised care.[5]
• Provide person-centred palliative care for people with advanced or terminal COPD, respecting expressed wishes and advance instructions, reviewing care goals during the agonal or final-days phase, and supporting families and carers psychologically and socially.[7][8]
• Strengthen continuing professional education and advance epidemiological, basic, clinical and translational research, including interdisciplinary projects, accredited networks of research centres and excellence groups, and primary-care research on COPD care.[8][9]

Implementation

The strategy is implemented through cooperation between the Ministry of Health, Social Services and Equality, autonomous communities, the National Institute of Health Management, scientific societies and health-service providers.[1]Its update drew on the experience and knowledge of Technical and Institutional Committees.[3]Delivery is centred on health centres and coordinated across primary care, specialised care, hospitals, home services, palliative-care support teams, nursing staff and specialist tobacco-dependence units.[3][4][7]

• Implement prevention measures through health education in schools, tobacco-control activities, inspections and other compliance controls under Law 28/2005, and collection by autonomous communities of information on environmental tobacco-smoke exposure, complaints, inspections and infringements.[3]Maintain surveillance of smoking-initiation age as an early-warning measure, although the former target to delay initiation by six months was removed because the indicator was stable and offered limited scope for intervention.[10]
• Equip health centres with diagnostic resources, conduct targeted spirometry with bronchodilator testing, and designate a nurse to oversee compliance with spirometry quality criteria.[4]Offer smoking-cessation programmes or referral to specialist tobacco-dependence units, including training for medical and nursing personnel caring for people with COPD.[4][5][7]
• Deliver chronic care through nursing plans, at least annual review for people with moderate or severe COPD, monitoring of pharmacological and non-pharmacological treatment, mobile home respiratory therapies and protocol-based rehabilitation programmes.[5]The strategy envisages possible public financing or co-financing of pharmacological smoking-cessation treatment for people with COPD, but provides no monetary amount or detailed financing mechanism.[4]
• Use clinical pathways, protocols and care processes for exacerbations; provide discharge plans and treatment information to primary-care teams; and ensure that hospitals have non-invasive ventilation, monitoring equipment and trained staff according to local capacity.[5]
• Coordinate palliative care across primary care, specialised care, home services and local support teams; establish procedures to identify and assess palliative-care needs; and provide support for patients, families and carers.[7][8]Reassess care objectives when the final-days phase is identified, intensify and evaluate comfort measures, and consider advance directives.[6][7]
• Maintain continuing-training plans through autonomous communities and support priority research through national and regional calls, interdisciplinary research and networks of accredited centres and excellence groups.[8]
• Monitor implementation using predefined indicators and an evaluation system established in the original strategy.[1]A Monitoring and Evaluation Committee agreed the methodology, and the evaluation was approved by the Plenary of the Interterritorial Council of the National Health System on 23 July 2013.[1]
• Improve indicator availability, reliability and historical comparability, as the evaluation identified insufficient reliable and accessible information to measure progress adequately.[2][10]Track spirometry activity, appropriateness of home oxygen therapy, exacerbation treatment, 30-day readmissions and emergency visits, the availability of protocols for the agonal period, and outcomes of comfort measures.[6][5][7]Use the Health Information Institute, Minimum Basic Data Set, Primary Care Information Service, Spanish National Health Survey, European Health Survey in Spain and other robust sources, while recognising possible sampling error in disaggregated survey estimates.[3]
• Address implementation gaps, as activities had commenced across all objectives but achievement was limited and uneven; reported progress was moderate overall, with relatively advanced smoking-cessation programmes and exacerbation-care pathways.[1]The source does not specify an overall budget, expenditure allocation, funding gaps or economic assumptions.[5][7][8]

Monitoring & Evaluation

Monitoring and evaluation combine a predefined indicator framework, autonomous-community reporting, health-information systems and committee oversight. The original strategy established an evaluation system and indicators, while a Monitoring and Evaluation Committee agreed the methodology; the resulting evaluation was approved by the Plenary of the Interterritorial Council of the National Health System on 23 July 2013.[1]Evaluation found that work had begun under all objectives, but implementation and achievement were limited and uneven, and later updates prioritised more reliable, accessible and comparable information.[1][2][10]

• Strengthen indicator availability, reliability and historical comparability to address the lack of sufficiently robust information for assessing progress towards objectives.[2][10]
• Collect autonomous-community data on implementation progress, care resources, equipment availability and clinical pathways, supporting assessment of organisational capacity and service delivery.[1]
• Monitor tobacco-control enforcement through information on environmental tobacco-smoke exposure, complaints, inspections and infringements, alongside surveillance of smoking-initiation age.[3][10]
• Use current smoking and daily smoking prevalence measures from the National Health Survey of Spain 2011/12 and the European Health Survey, whose adult questionnaires cover people aged 15 years and over.[9]
• Interpret survey estimates cautiously where results are disaggregated by autonomous community and sex, as sampling errors may be relevant and estimates may vary substantially between survey years.[3]
• Monitor early diagnosis through the number of spirometries with bronchodilator testing undertaken among symptomatic people aged over 40 with current or previous smoking exposure equivalent to 20 cigarettes daily for 10 years.[6]
• Assess the accessibility and quality of forced spirometry through monitoring arrangements, defined quality criteria and a designated nurse responsible for compliance.[4]
• Measure home oxygen therapy through the proportion of people with chronic obstructive pulmonary disease receiving it and the proportion receiving it appropriately.[6]
• Monitor care quality through systems assessing the appropriateness of pharmacological treatment, treatment during exacerbations and the use of non-pharmacological interventions.[4][5]
• Track unplanned hospital readmissions and emergency visits within 30 days of discharge, and support continuity of care by providing primary-care teams with discharge information containing treatment and care plans.[5]
• Evaluate chronic-care delivery through nursing care plans, including at least annual review for people with moderate or severe disease, and through structured respiratory rehabilitation in primary and specialised care.[5][6]
• Use the existence of a clinical practice protocol for the agonal period as an explicit indicator for end-of-life care.[3][6]
• Use information and registration systems to identify, manage and evaluate palliative-care processes, including comfort measures and their results during the final-days phase.[7]
• Include patients’ expressed wishes and advance instructions in care protocols and reassessment of care objectives, with continuing professional education supporting adherence to these wishes.[7]
• Maintain accountability through collaboration among autonomous communities, the National Institute of Health Management, scientific societies and the Ministry of Health, Social Services and Equality.[1]

Costing & Financing

No explicit budget, expenditure total, costing methodology, quantified resource requirement, funding gap, financing source or economic assumption is specified in the supplied extracts.[2][10][5][7][8][9]The extracts identify delivery resources, including diagnostic equipment, mobile respiratory therapies, rehabilitation, trained staff, palliative-care support and research networks, but do not attach monetary values or allocation arrangements to them.[4][5][7][8]

• Consider public financing or co-financing of pharmacological smoking-cessation treatment for people with chronic obstructive pulmonary disease; no amount, eligibility rule or funding mechanism is provided.[4]
• Provide structural, material and organisational resources in health centres for early diagnosis and care, without a quantified budget or resource-mobilisation plan.[3][4]
• Support continuing professional training and priority research through national and regional calls, including accredited research networks and excellence groups; the extracts do not specify the associated funding.[8][9]
• Maintain health-service resources for smoking-cessation programmes, specialist tobacco-dependence units, home oxygen and other respiratory therapies, but without stated costs or financing arrangements.[4][5]