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Workshop. Respiro è Vita: il 2009 anno per la Salute del RespiroLa BPCO: gestione clinica e organizzativa.

Dagli aspetti concettuali alla vita

26 Settembre 2009 Università di Milano

La gestione ospedaliera:

stratificazione del rischio

e costi dell'ospedalizzazione

Carlo Sturani

SC Pneumologia e UTIR AO C.Poma, Mantova

Stratificazione del rischio e costi dell’ospedalizzazione

• La stratificazione del rischio è uno dei punti chiave della gestione delle malattie cronicheprogressive, invalidanti e potenzialmente mortali nelle fasi di riacutizzazioni

• La stratificazione del rischio dal punto di vista concettuale, epidemiologico, del risk management e dell’equità distributiva è un processo complesso e ricco di conseguenze


La stratificazione del rischio

• è uno dei punti chiave per la gestione appropriata gestione appropriata dell’ospedalizzazione

• ed influenza i costi



• Nella fase cronica stabile

• Nella fase cronica avanzata• Nella fase cronica avanzata

• Nella fase cronica d’insufficienza d’organo

• Nelle fasi di riacutizzazione

The COPD screw ERS 2009

INCREASED-EXACERBATIONS-H. ADMISSIONS-MORTALITY-PREVALENCE

INSUFFICIENTDIAGNOSISTREATMENT

-PREVALENCE

HUGENUMBER WITH ADVANCED STAGE/CHRONIC RESPIRATORY FAILURE

TREATMENT

Epidemiologia delle malattie

respiratorie croniche,

mortalità e costimortalità e costi

ERS 2008

MMWR Sept 2004; 53CDC indicators for chronic disease

surveillance

1. Le previsioni più ottimistiche indicano che la

mortalità per BPCO aumenterà ulteriormente,

Healthy people 2010 objectives:

Reduce deaths from COPD among adults

mortalità per BPCO aumenterà ulteriormente,

del 50% nei prossimi 15 anni

J COPD 2008;5:187-200

J c

op

COPD CORONARY ARTERY

DISEASE

Unstable COPD: Unstable angina:

� Worsening of dyspnoea cough or sputum

� Worsening of chest pain

� RR < 24 � No ECG changes

� Dyspnoea < 4 on 0-10 scale � Normal laboratory results

Celli and Barnes, ERJ 2007

Exacerbation: Myocardial infarction:

� Worsening of dyspnoea cough orsputum

� Chest pain

� Dyspnoea ≥ 4 on 0-10 scale � Abnormal ECG- Abnormal serum enzyme

Ventilatory insufficiency: Cardiogenic shock :

� Same plus elevation of PaCO2 in

arterial blood gases

� Same syndrome plus shock

Mortality comparisons across diseases

COPD Myocardial Infarction

69

Moderate

Severe

3

50

35

0 20 40 60 80

No Shock

Shock

Moderate

%

Swedish Registry 2008, GUSTO-1 Trial 2007

Disease trajectory of COPD in the last years of life

differs from the more predictable decline in lung cancer

Differences in Health Care Utilization at the End of Life Among Patients With COPD and Patients With Lung Cancer.

Arch Intern Med. 2006;166:326-331

Patients with COPD

• were more likely to have been hospitalized (39.8% for COPD vs 18.5% for lung cancer)

• had 5 times the odds of spending more than 2 weeks in an ICU

• and had twice the odds of being readmitted to the ICU

Gestione della BPCO: EU 2009

•10% dei ricoveri medici (seconda causa di ricovero m)

•11-15% mortalità media del paz ricoverato con riacutizz.

•25- 40% mortalità con insufficienza respiratoria

•Metà dei decessi entro 3 mesi dalla dimissione

•30-40% ricovero “ripetuto” entro 3 mesi, 50% entro 6m

DispneaFunzione respiratoria

•41.000 giorni lavoro persi/100.000 ab anno (26 bil.euro)

2000

IV causa di morte

2020

III causa morte

500mila 6 milioni

European Respiratory Society and European Community Lung White Book 2004

Ricoveri

100000

120000

140000

160000

0

20000

40000

60000

80000

100000

D UK E I

1994

1999

Italia (ISS)BPCO 7°causa di ricovero 2°DRG Medico

Johnston AK, Mannino DM. Epidemiology of COPD exacerbations.In: Wedzicha JA, Martinez F, editors. Exacerbations Of Chronic

Obstructive Pulmonary Disease (COPD). New York: InformaHealthcare; 2008.

• In-hospital mortality varies between less than 10% and 60%,between less than 10% and 60%,

• based on the severity level of the population studied.

Type of chronic condition in 1393 patients admitted to 99 Italian ICUs

Apolone G. Intensive Care Med 1996

10

12

14

16

cancer

cirrhosis

in ITALIA in UTI

0

2

4

6

8 diabetes

cardiopathy

COPD

ANSA/SIARTI 4 DIC 2005: MANCANO 4000 letti di rianimazione

35% dei pazienti in UTI hanno PAT RESP o NM con indicazione a ricovero in UTIR

Health Policy 2005: 289-301

Nazione % letti UTI %rifiuto ricovero UTI

% occupazione letti UTI

USA 15% 3% <75%

Svezia 9%

Olanda 7%Olanda 7%

Francia 6% 25%

Germania 5%

Inghilterra 4% 31%

Spagna 4%

Grecia 3%

Italia 1.7% >60% >120%

44% of the patients survived the episode of ARF

survived

died

Levy et al. Critical Care Med. 2004

WHO. Health Policy 2005: 289-301Nazione % letti UTI %rifiuto

ricovero UTI

%rifiuto ricovero UTI

>70 anni

USA 15% 3%

Svezia 9%

Olanda 7%Olanda 7%

Francia 6% 25% 70%

Germania 5%

Inghilterra 4% 31%

Spagna 4%

Grecia 3%

Italia 1.7% >60% ??????????

��1616 %% ofof hospitalhospital admissionsadmissions inin EUEU

��2525--6565%% needneed HospitalizationHospitalization

THE COSTS OF COPD EXACERBATIONSTHE COSTS OF COPD EXACERBATIONS

Wedzicha and Seemungal, Lancet 2007

“COPD exacerbations are now

the most common cause of medical

hospital admission in the EU”

Epidemiology and costs of COPD.Chapman K.R., Mannino D.M., Soriano J.B. et al. ERJ. 2006; 27: 188–207.

• Some studies have shown that

the cost of hospital stay represents

40–63% of the total direct costs,40–63% of the total direct costs,

• reaching up to 63% in severe

patients

Economic consequences

Observational studies performed in

primary care Centres observed that

16-22% of patients having16-22% of patients having

exacerbations were admitted

during 1 yr

Pena VS, Miravitlles M, et al. Geographicvariations in prevalence

and underdiagnosis of COPD:results of the IBERPOC multicentre

Epidemiological study. Chest 2000; 118: 981–989.

Exacerbations of COPD. B.R. Celli and P.J. BarnesEur Respir J 2007; 29: 1224–1238


Failure implies a cost that is three times

higher than the cost of management of the higher than the cost of management of the

exacerbation,

Particularly due to the high cost of

hospitalisation.

Miravitlles M et al. Characteristics of a population of COPD patients identified from a population-based study. Respir Med 2005; 99: 985–995


This is particularly important considering that a

recent study demonstrated that

• patients with st IV COPD (FEV1 ,35% p) had

a significantly greater percentage of failures

than successful exacerbations,

• with 52% of failures requiring hospitalisation.

Exacerbations of COPD. B.R. Celli and P.J. BarnesEur Respir J 2007; 29: 1224–1238


However, these costs may not be applicable to

other Countries because of the differences in other Countries because of the differences in

• reference prices,

• management practices

• and healthcare systems.

The burden of COPD in Italy:resultsfrom the Confronting COPD survey.

Dal Negro R, Rossi A, Cerveri I. Respir Med, 2003. 97:s43–50.

A nation-wide survey in 2003 the cost was

confirmed to vary as a function of clinical

severity of COPD, severity of COPD,

• reaching 7000/patient/year in the most

severe cases.

• Mean cost/patient/year 2100

• Hospital admission has been found to

account for 75% of the total cost

Costs of chronic obstructive pulmonary disease (COPD) in Italy: The SIRIO study (Social Impact of Respiratory Integrated Outcomes). Respir Med, 2008. 102:92–101.

• As assessed in the US and in Italy, mean annual cost of COPD has progressively increased over the progressively increased over the last few years,

• increasing by 35% (2003��2008) to reach an average of 2720/patient

The impact of aging and smoking on the future burden of copd: a model analysis in the Netherlands.

Am J Respir Crit Care Med 2001; 164: 590–596.


• The costs of managing acute • The costs of managing acute exacerbations of COPD are high,

• particularly because of the high costs associated with relapse

Discharge planning and home care for endstage COPD.

J. Escarrabill Eur Respir J 2009; 34: 507–512

• the Risk Factors of COPD Exacerbation

Study (EFRAM) found that 63% of

patients were readmitted during the

year following an exacerbationyear following an exacerbation

• For this reason, discharge support for the

most seriously ill patients is a key issue in

minimising the impact of the current acute

episode and preventing future relapses.

The impact of aging and smoking on the future burden of copd: a model analysis in the Netherlands.

Am J Respir Crit Care Med 2001; 164: 590–596.


Strategies to improve the outcome of ambulatory

treatment of exacerbations should be very cost-

effective, especially in more severe patients who

are at increased risk of being admitted to hospital

as a consequence of therapeutic failure.

Resource use and risk factors in high-cost exacerbations of COPD.

Oostenbrink JB. Respir Med 2004. 98:883–91.

•A small proportion of COPD (10-20%),

experiencing acute exacerbations, experiencing acute exacerbations,

accounts for over 70 percent of costs

as a result of COPD due to

emergency visits and hospitalizations.

BPCO RIACUTIZZAZIONI:RICOVERO IN HStoller New Engl J Med 2003

MORTALITA’m range

____________________________________________________

� PS/DEU �� 30-65% RICOVERO �� 11% 7-18%15 % *

Mortalità della BPCO ospedalizzata superiore �� alla mortalità dell’ infarto

15 % *

� RICOVERO �� 20-35% IRA �� 28% 9-65%

� IRA �� 15-26% VM �� 36% 24-65%

____________________________________________________

*NICE 2005



• A domicilio

• Nei DEU

• In degenza generale e specialistica

• In Terapia semi intensiva Respiratoria

• ed intensiva generale

Variables including

• using long term oxygen therapy,

• having low health status

• or poor health related quality of life

• and not having routine physical activity

were all associated with an increased risk

of admission and readmission to hospital.

• PaCO2 was shown to be• PaCO2 was shown to be

• an independent risk factor for hospital

admission for an acute exacerbation of

COPD

In this review, 3 predictive factors:

• “previous hospital admission”, • “previous hospital admission”,

• “dyspnea”

• “oral corticosteroids”

were all found to be significant risk factors of readmissions.

• Comorbidity does not appear to be a risk factor

for frequent exacerbations,

• but a risk factor for severe life threatening • but a risk factor for severe life threatening

exacerbations that can provoke admission.

• special attention should be paid to the diagnosis of

coexisting disease and its association with COPD

admission.

• Older age was associated with shorter time to

first readmission and increased risk of

hospitalization in several studies

(Lau et al 2001; Soler-Cataluna et al 2005; Gadoury

et al 2005).

• This may be related to the higher degree of

disability and comorbidity in the older population.

• it has been demonstrated that prompt treatment by a physician

• is associated with better outcomes

Use and utility of an early presentation and intervention in COPD.Hurst JR. ERS Wien 15 sept 09

• Unit of Respiratory Medicine

• Established telephone service (24h, 7/7d) for patients and

carers with COPD to facilitate early treatment

• Recruitment of patients with high risk of HA

(previous AECOPD and or severe disease)

• Medications optimized,pts were given an emergency course of

AB and steroids to have at home

• 24H access to health care professionals

who knew them and who they knew….

Use and utility of an early presentation and intervention in COPD (EPIC).Hurst JR. ERS Wien 15 sept 09

• 45 patients with complete 6 mos fup

• 14 died• 14 died


• 80% patients made unplanned calls to the service

• Average rate call per patient 1 every 53 patient days

(13-183)(13-183)

• Average call duration 9 mins

• 3% overnight

• 36% of calls concerned symptoms deterioration

• Satisfaction 4.8/5 (1 peggio-5molto meglio)


• Most patients are willing to use a 24/7 COPD advice lineadvice line

• These data will be of use in determining the cost effectiveness of such services

ACIDOSI E OSPEDALIZZAZIONE

• DEVONO ESSERE RICOVERATI SOLO I PAZIENTI IPERCAPNICI E/O CON ACIDOSI?

• PERCHE’ più di >20 linee guida • PERCHE’ più di >20 linee guida internazionali indicano ulteriori criteri (da 7 a 18 criteri) di per se sufficienti a considerare necessaria l’ospedalizzazione?

Acidosis in COPD exacerbations admitted to hospitals – the UK national COPD audit 2008. Roberts C. Clinical Effectiveness Unit.

Royal College of Physicians, London. ERS Wien 15 sept 09, 605s

Few data of the true prevalence of acidosis in HA

232 Hospitals, data in 9716 COPD m73 yrs

• 87% ABG on HA• 87% ABG on HA

• 20% acidotic (pH<7.35)

• 7% very severe acidosis (pH<7.26)

Acidosis in COPD exacerbations admitted to hospitals – the UK national COPD audit 2008. Roberts C. Clinical

Effectiveness Unit. Royal College of Physicians, London. ERS Wien 15 sept 09, 605s

• 30% in ambulance and DEA FIO2 > 35

(recorded only 50%)

• 7% non acidotic became later acidotic• 7% non acidotic became later acidotic

• 26% cumulative acidotic

• 12 hours post HA lowest pH

(64% receiving FIO2>28)!

NIV mortality in clinical practice – the UK national COPD audit 2008.Roberts C. Clinical Effectiveness Unit. Royal College of Physicians, London. ERS Wien 15 sept 09, 604s

• 1077/9716 patients received NIV

• 102 patients with pH>7.35

• 25 % in H mortality• 33% 90 days mortality

• The high mortality observed in 2004 was repeated in 2008

NIV mortality in clinical practice – the UK national COPD audit 2008. Roberts C. Clinical

Effectiveness Unit. Royal College of Physicians, London.

ERS Wien 15 sept 09, 604s

HA AECOPD treated with NIV

% Mortality during admission/90d

ABG pH <7.26 7.26-7.34 >7.34ABG pH <7.26 7.26-7.34 >7.34

Lowest pH on HA 27/35 17/26 32/37

Lowest pH post HA 49/52 32/35 8/14

Acidosis in COPD exacerbations admitted to hospitals – the UK national COPD audit 2008. Roberts C. Clinical

Effectiveness Unit. Royal College of Physicians, London. ERS Wien 15 sept 09, 605s

• Outcome are worse for those ventilated with the lowest pH later in the admission.

• There are a number of COPD pts with a normal pH admission who receive NIV who have a high mortality.

• This group needs further investigation.

When AECOPD leads to an acidotic state,

patients often require admission to the patients often require admission to the

intensive care unit for assisted ventilation,

with a poor prognosis in survivors

after discharge.

mortality was independently related to

• age,

• hypercapnia, • hypercapnia,

• and frequency of severe exacerbations,

• particularly if these require admission to hospital.

Nonacidotic AECOPD

also accounts for

considerable hospitalization

A study of patients hospitalized for nonacidotic AECOPD found that independent predictors of

mortality were

• Quality of life, • Quality of life,

• marital status,

• depressive symptoms,

• prior hospital admission,

• and comorbidity,

• 10% died

Predictors of 6-Month Mortality in Elderly Patients with

Mild Chronic Obstructive Pulmonary DiseaseDischarged After Acute Nonacidotic Exacerbation

• 15 transferred to the intensive care

unit

Tasso di ospedalizzazione?

A clinical audit of COPD hospitalizations in 3 Scandinavian Hospitals.Liaaen ED. ERS Wien 15 sept 2009, 601s

• AE COPD requiring HA represent and independent predictor fo poor patient prognosis

• Scandinavia 26(28-24) COPD HA /10000inh

• Spain 25(30-16) COPD HA /10000inh in 7 health regions from 30 to 16

A clinical audit of COPD hospitalizations in 3 Scandinavian Hospitals.

Liaaen ED. ERS Wien 15 sept 2009, 601s

• COPD HA /10000inh 26(28-24)

• Mean LOS d 7.7 – 9.2

• Current smokers % 35 – 26

• Patients on LTOT % 15 – 21

• Received NIV % 22 – 8

• Received AB % 59 – 71

A clinical audit of COPD hospitalizations in 3 Scandinavian Hospitals.

Liaaen ED. ERS Wien 15 sept 2009, 601s

• Significant differences with respect to treatments with NIV and AB were observed between centres and countriesobserved between centres and countries

• Some of these findings may reflect different organization of health care

AUDIPOC. National clinical audit on COPD exacerbations in Spain. Mortality and readmissions. Influence of hospitalization department.

Hernandez C. ERS Wien 15 sept 2009, 601s

• 1203 COPD, 30 public hospitals in Spain

• 43% clinical relevant comorbidity (CI 2.7)

• 55% admitted to the Pneumology dept

• 39% admitted to Internal Med dept

National clinical audit on COPD exacerbations in Spain. Mortality and readmissions.Influence of hospitalization department.

AUDIPOC. Hernandez C. ERS Wien 09, 601s

Department Pneumology Internal med

1203 COPD, 30 public hospitals in Spain, 43% clinical relevant comorbidity (CI 2.7)

% HA 55 39

Mortality in H % 3.5 6.3*

Mortality 90 d % 8.3 11.2

Readmission 90 d % 36 39

AUDIT nei DEA

Complex admission decisions

• The authors confirmed five of

the seven testable indications

Factors associated with hospital admission among emergency department patients with COPD exacerbation.

Tsai CL. Acad Emerg Med. 2007 Jan;14(1):6-14.

the seven testable indications

for hospital admission in the

GOLD guidelines.

Regione Lombardia 2007

• Most patients (70%) presented to the

Acute exacerbations of COPD: delay in presentation and the risk of hospitalization.

Chandra D. COPD. 2009 Apr;6(2):95-103

ED > 24 hours after symptom onset,

and most (61%) were hospitalized

• On multivariate logistic regression analysis,

after adjusting for 12 potential confounders



• a delay in presentation > or = 24

hours was associated with a over two-

fold increase in the odds of admission

• Early presentation should be

emphasized to patients and

caregivers to advance efforts



caregivers to advance efforts

to decrease the morbidity,

mortality, and costs of AECOPD

treatment.

• Approximately one third of exacerbations

were recurrent exacerbations.

Temporal clustering of exacerbations in COPD.

Hurst JR, Wedzicha JA. BMC Med. 2009 Aug 7; 7:40.

• Exacerbations are not random events but

cluster together in time such that there is a

high-risk period for recurrent exacerbation in

the 8-week period after an initial excerbation.

Risk factors and outcomes associated with COPD exacerbations requiring hospitalization.

BBahadori K. Jul;16(4):e43-9. Can Respir J. 2009 Jul;16(4):e43-9.

• During the study period, 38% of subjects were readmitted at least once.

• Comparative analysis among the three hospitals identified a significant difference in readmission rates

(54%, 36% and 18%, respectively).

Risk factors and outcomes associated with COPD exacerbations requiring hospitalization.BBahadori K. Can Respir J. 2009. Jul;16(4):e43-9.

Independently associated with frequent readmissions for AE.

�preadmission home oxygen use (P=0.001),

�other chronic respiratory disease P=0.03)

�shorter length of hospital stay (P=0.021)

Exacerbations de BPCO:

Audit de pratique dans les services d’urgences en FranceRev Mal Respir 2006; 23:49-57

La mission première du service d’urgence

serait donc plutot d’èvaluer la gravitè

de ces patients a fin de les orienter vers

• un service de pneumologie,

• des soins intensifs de pneumologie

• or de reanimation

Current and Projected Workforce Requirements for Care of the Critically Ill and Patients with Pulmonary Disease.

Can we meet the Requirements of an Aging population? COMPACCS.

ANNI PNEUM

% G

G/1000 ab PNEUM

2010

UTI/UTIR

2010

<65 32 38<65 32 38

65-75 37 261

>75 31 634

BPCO , IR, Polmonite

85 JAMA 2000 284:2762

+35% +30%

In EU c’è un impellente bisogno di Terapie semi intensive

ad alta intensità e specializzazioneTask force soc europea TI . Intens Care Med 2008

• Riduzione totale del n PL ospedale

• Aumento indicazioni a ventilazione meccanica non

invasiva (VMNI) in particolare per BPCO

• Aumento relativo di pazienti critici RESPIRATORI E

CARDIACI in H

• “Disinvoltura” interventistica (operare tutto a qualsiasi

costo)

• Aumento dei pazienti dipendenti da VM

• Aumento inappropriato delle tracheostomie

Costs of the COPD. Differences between intensive care unit and respiratory intermediate care unit.

GIVITI . Respir Med 2005; 99:894-900

MULTICENTRE/PROSP. RICU (6) ICU (15)

TRACHEOSTOMY % 6% 26%

• No differences in mortality

• Total cost per patient was lower in RICU

COST/PT/DAY

EURO 754 1507

Eur Respir J 2002; 20: 1343-1350

A. Corrado, C. Roussos, N. Ambrosino, M. Confalonieri, A. Cuvelier, M. Elliott, M. Ferrer,

M. Gorini, O. Gurkan, J.F. Muir, L. Quareni, D. Robert, D. Rodenstein, A. Rossi, B.

Schönhofer, A.K. Simonds, K. Strom, A. Torres, S. Zakynthinos

42,945

50

Percenta

ge D

istr

ibution

25,7

11,48,6

5,72,9

2,9

0

510

15

20

25

3035

40

45

Percenta

ge D

istr

ibution

Germ

any

Italy

Turkey

France

UK

Spain

Aust

ria

Respiratory Intensive Care Units in Italy from 1965 to 2006

50

60

70

80N

° R

ICU

0

10

20

30

40

50

N°

RIC

U

65 75 85 90 92 94 96

Years

2006

Riconosciute Totali

(n.49) (n.72)

Nord 61,2% 57,0%

Centro 20,4% 20,8%

Sud-isole 18,4% 22,2%3(2)

10(9)

2(2)

3(2)

2(1)

13(10)

2(2)

3(2)

0(0)

6(3)

4(3)

3(2)

3(2)

8(4)

0(0)

Distribuzionegeografica

20062006

5(2)6(3)

1(1)

3(3)

1(0)

0(0)

0(0)

1996 totale 26Nord = 17 (65.4%)Centro = 5 (15,4%)Sud+Isole = 4 (19,2%)

326 centres providing HMV IN EUROPE

> 21,000 patients on HMV

QUESTIONNAIRE FROM SELECTED CENTERS

14

17

2

17

16

Eurovent

IX/2001 – VI/ 2002

44 CENTRI CHE DIMETTONO PAZIENTI ASSISTITI CON VMD

In ITALIA hanno risposto al questionario

4614

5

22

20

9

17

44

7

15

58

15

PSSN 2006-08 e PSSR Lomb 2006-08

Malattie dell’apparato respiratorio e pneumologia

Offerta di alta specialità

� Assistenza domiciliare respiratoria integrata ad alta intensità (ADR AI)/(Cure domiciliari di III livello/ODR)

� 14 regioni su 20 hanno norme regionali per OTLT� 14 regioni su 20 hanno norme regionali per OTLT

� Solo 3 regioni (Lomb, Ven e ER hanno registro OTLT)

� VMD LG in 10 regioni , registro in 2

�

� ADR e telemedicina in 9 regioni

� ADR attivata nel 25% delle regioni in più del 50% delle ASL

Commissione Mal Respir. Regione Lombardia 2001-7GAT BPCO e Insufficienza respiratoria 2009

Setting di ospedalizzazione vs gravità della BPCO riacutizzata

•Unità operativa complessa di Medicina generale:

-insufficienza respiratoria assente, -non stadio III –IV

• Unità operativa complessa di Pneumologia :

-stadio II-IV,

-acidosi respiratoria con pHa da 7.35 a 7.30se livello di monitoraggio ed assist. Adeguati (almeno 240min)se livello di monitoraggio ed assist. Adeguati (almeno 240min)

Unità di cura per l’insufficienza respiratoria avanzata(semintensiva): -rischio di acidosi respiratoria,

-acidosi respiratoria pH da 7.35 a 7.20,-comorbilità,

-pazienti già in O2-terapia o in ventilazione meccanica domiciliare,

-necessità di ventilazione meccanica non invasiva

•Unità di terapia intensiva generale:-pH <7.20 e/o MOF

Cure integrate

CURE INTERMEDIEVS FASE STABILEVS RIACUTIZZAZIONI

OSPEDALEVS RIACUTIZZAZIONIVS FASE AVANZATA

TERRITORIO

OSPEDALE

Outcome Predicted by physicians

Observed

Survival Survival

(6 months) 49% 62%

Survival

(6 months)

In patients with the worst prognosis (1/5)

10% 50%

44% of the patients survived the episode of ARF

survived

died

Levy et al. Critical Care Med. 2004

Comunità scientifica

(pneumologica)

27 dicembre 2008

L’insufficienza respiratoria (DRG87)

ESCE DALLA

FASCIA PROTETTA

DEI RICOVERI DA RIMBORSARE ALLE

“aziende “ Ospedaliere

Cronicità. Le cure negate?How well do we care for patients with COPD?

A Comparison of care and quality of life in COPD and

lung cancer.Gore JM.Thorax 2000;55:1000-06

• I malati con tumore polmonare hanno

più assistenza più assistenza

• rispetto ai malati con malattie croniche

respiratorie nonostante gravità dei sintomi

e necessità assistenziali

• siano molto simili

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