Pharmacoeconomic Study of Antibiotic Therapy for Acute Exacerbations of Chronic Bronchitis and Chronic Obstructive Pulmonary Disease in Latin America

array:19 ["pii" => "13055460" "issn" => "15792129" "estado" => "S300" "fechaPublicacion" => "2003-12-01" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Arch Bronconeumol. 2003;39:549-53" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 5699 "formatos" => array:3 [ "EPUB" => 137 "HTML" => 3757 "PDF" => 1805 ] ] "itemSiguiente" => array:15 [ "pii" => "13055461" "issn" => "15792129" "estado" => "S300" "fechaPublicacion" => "2003-12-01" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Arch Bronconeumol. 2003;39:554-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 6961 "formatos" => array:3 [ "EPUB" => 153 "HTML" => 5682 "PDF" => 1126 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Prevalence of Chronic Obstructive Pulmonary Disease and Risk Factors in Smokers and Ex-Smokers" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "554" "paginaFinal" => "558" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Prevalencia y factores de riesgo de EPOC en fumadores y ex fumadores" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "JI Jaén Díaz, C de Castro Mesa, G Gontán, MJ Salamanca, F López de Castro" "autores" => array:5 [ 0 => array:2 [ "Iniciales" => "JI" "apellidos" => "Jaén Díaz" ] 1 => array:2 [ "Iniciales" => "C" "apellidos" => "de Castro Mesa" ] 2 => array:2 [ "Iniciales" => "G" "apellidos" => "Gontán" ] 3 => array:2 [ "Iniciales" => "MJ" "apellidos" => "Salamanca" ] 4 => array:2 [ "Iniciales" => "F" "apellidos" => "López de Castro" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13055461?idApp=UINPBA00003Z" "url" => "/15792129/0000003900000012/v0_201307090853/13055461/v0_201307090853/en/main.assets" ] "itemAnterior" => array:15 [ "pii" => "13055459" "issn" => "15792129" "estado" => "S300" "fechaPublicacion" => "2003-12-01" "documento" => "article" "crossmark" => 0 "subdocumento" => "fla" "cita" => "Arch Bronconeumol. 2003;39:544-8" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 5183 "formatos" => array:3 [ "EPUB" => 146 "HTML" => 4091 "PDF" => 946 ] ] "en" => array:11 [ "idiomaDefecto" => true "titulo" => "Comparison Between Automatic and Manual Analysis in the Diagnosis of Obstructive Sleep Apnea-Hypopnea Syndrome" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "544" "paginaFinal" => "548" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Comparación entre el análisis automático y manual de la polisomnografía convencional en el diagnóstico del síndrome de apnea-hipopnea obstructiva del sueño" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "B Barreiro, G Badosa, S Quintana, L Esteban, JL Heredia" "autores" => array:5 [ 0 => array:2 [ "Iniciales" => "B" "apellidos" => "Barreiro" ] 1 => array:2 [ "Iniciales" => "G" "apellidos" => "Badosa" ] 2 => array:2 [ "Iniciales" => "S" "apellidos" => "Quintana" ] 3 => array:2 [ "Iniciales" => "L" "apellidos" => "Esteban" ] 4 => array:2 [ "Iniciales" => "JL" "apellidos" => "Heredia" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13055459?idApp=UINPBA00003Z" "url" => "/15792129/0000003900000012/v0_201307090853/13055459/v0_201307090853/en/main.assets" ] "en" => array:14 [ "idiomaDefecto" => true "titulo" => "Pharmacoeconomic Study of Antibiotic Therapy for Acute Exacerbations of Chronic Bronchitis and Chronic Obstructive Pulmonary Disease in Latin America" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "549" "paginaFinal" => "553" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "M Miravitlles, JR Jardim, T Zitto, JE Rodrigues, H López" "autores" => array:5 [ 0 => array:3 [ "Iniciales" => "M" "apellidos" => "Miravitlles" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "JR" "apellidos" => "Jardim" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "affb" ] ] ] 2 => array:3 [ "Iniciales" => "T" "apellidos" => "Zitto" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] 3 => array:3 [ "Iniciales" => "JE" "apellidos" => "Rodrigues" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "affd" ] ] ] 4 => array:3 [ "Iniciales" => "H" "apellidos" => "López" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "affc" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servei de Pneumologia, Institut Clínic de Pneumologia i Cirurgia Toràcica (IDIBAPS), Hospital Clínic, Barcelona, Spain." "etiqueta" => "a" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Servicio de Neumología y Grupo de Farmacoeconomía en EPOC, Universidade Federal de São Paulo, São Paulo, Brazil." "etiqueta" => "b" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Centro de Infectología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina." "etiqueta" => "c" "identificador" => "affc" ] 3 => array:3 [ "entidad" => "Grupo de Farmacoeconomía en EPOC, Universidade Federal de São Paulo, São Paulo, Brazil." "etiqueta" => "d" "identificador" => "affd" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estudio farmacoeconómico del tratamiento antibiótico de las agudizaciones de la bronquitis crónica y la EPOC en Latinoamérica" ] ] "textoCompleto" => "IntroductionChronic respiratory disease, especially chronic bronchitis and chronic obstructive pulmonary disease (COPD), is one of the most common causes of demand for primary health care. Recent studies in Spain estimate that 8% to 10% of the population over 40 years of age may have COPD1,2 and that the percentage may be as high as 20% for men over 65 years of age.2 A Brazilian population study revealed a prevalence of chronic bronchitis of 12.7% of those over 40 years of age.3 Epidemiological studies have not been published for many Latin American countries, but mortality statistics show COPD to be one of the most common causes of death, surpassed only by cardiovascular diseases and cancer.4Respiratory symptoms may increase suddenly in both chronic bronchitis and COPD, producing the crises we know as exacerbations, the majority of which stem from infection.5 Key to treating infectious exacerbations of chronic bronchitis and COPD is the administration of antibiotics with adequate ranges of action, easy dosing regimens, and reasonable cost. Furthermore, evaluation of the results of different antibiotics used in treating exacerbations is necessary in order to establish the most cost-effective options. The dilemma in recent years of ever-increasing health care costs paralleled by necessarily limited resources calls for economic evaluation of pharmacological treatments.6 Such an evaluation applied to chronic bronchitis and COPD is pivotal for social and health care management as, according to a recent study, COPD patients suffer a mean of 2 exacerbations per year, 90% of which are treated with antibiotics and 10% of which require hospital admission.7In a context such as the Latin American one, pharmacoeconomics acquires special relevance due to the difficult economic situation in some countries. Identification of the factors determining health care costs is prerequisite to establishing strategies for more efficient use of resources.8 The present study estimates the direct health care costs derived from treating exacerbations of chronic bronchitis and COPD in various Latin American countries using economic data obtained in each country and the results of a recent Spanish pharmacoeconomic study.9MethodThe present pharmacoeconomic study uses data from an analysis of the direct health care costs of treating patients with chronic bronchitis or exacerbated COPD. Based on these data, estimates of costs were calculated for various countries in Latin America--Argentina, Brazil, Columbia, Ecuador, Mexico, Peru, and Venezuela--factoring in the real costs of pharmaceuticals and health care expenses in each country.For our analysis we started with a Spanish study on the use of health care resources in primary treatment of exacerbations of chronic bronchitis and COPD in Spain.9 The study included a description of the treatments used, the percentage of therapeutic failure, and the percentages of subsequent medical visits, hospital emergency room treatment, and hospitalizations involved in treating patients with exacerbations (Table 1). Each pharmaceutical was given a weight derived from the percentage of its use in treating the exacerbations; similarly, subsequent health care acts were weighted according to their frequency. Due to the absence of studies on the use of resources for treating exacerbations of chronic bronchitis and COPD in Latin America, we applied the same weights (Table 1) for calculating the costs in the Latin American countries studied. That is, the global rate of failure in Latin America would be considered as 21%; emergency room visits, 6.7%; and hospitalizations, 3.4%.9,10 These assumed rates may differ considerably from certain local health care rates; however, applied to each country, they allow for a comparison of exacerbation costs and therapeutic failure derived from the costs of the various national health care resources without the interference of factors such as patient characteristics or disease management.<img src="260v39n12-13055460tab01.gif"></img>Pharmacoeconomic AnalysisThe costs used in calculating the global rates were the so-called direct costs--those related to the consumption of health care system resources--in order to ascertain variations in the consumption of system resources. Not included, for example, were costs incurred by patients for transportation to health care centers or the loss of time involved. In other words, the consumption of resources evaluated was the cost of treating the exacerbation and the cost of failure of this treatment; the latter cost was limited to the following 3 factors: subsequent ambulatory visit, emergency room visit, or hospital stay.The diagram (Figure 1) was the same as that used in recent studies on health care costs of treating exacerbation of chronic bronchitis and COPD.9<img src="260v39n12-13055460tab02.gif"></img>Figure 1. Plan of action for treating exacerbations. 1. Initiating treatment of the exacerbated patient. 2. During the 30 days following initiation no failure is produced; therefore, no presentation at ambulatory or hospital center is observed. 3. A failure is produced, implying that health care resources will be requested. 4. One option is ambulatory service. 5. Another option is hospital emergency room treatment. 6. Ambulatory service resolves the problem without hospitalization. 7. Ambulatory service leads to hospitalization. 8. Emergency room treatment resolves the problem without hospitalization. 9. Emergency room treatment leads to hospitalization.The costs included in our analysis were the following: a) the costs of each treatment option included in point 1 of Figure 1; b) the cost of the ambulatory visit; c) the cost of the emergency room visit, and d) the cost of the hospital stay.To calculate the costs of the ambulatory visits, emergency room visits, and hospital stays, we used the official costs provided by health care authorities or obtained from public referral health care centers. In the case of emergency room visits we included the cost of a single chest x-ray and a hemogram. When there was a lack of information on the mean length of hospital stay per exacerbation of COPD in the various countries, we calculated for 8 days, in accordance with published studies.11,12 The cost of pharmacological treatment was obtained from the official registered prices of the active ingredients of pharmaceuticals available in each country.The equation for obtaining the final cost-per-patient result was the following:<img src="260v39n12-13055460tab03.gif"></img>where v is the number of ambulatory visits; p, the number of patients; cv, the unit cost of an ambulatory visit; em, the number of emergency room visits; cem, the unit cost of an emergency room visit; h, the number of hospitalizations; and cpw, the cost per day of a hospital stay on the pneumology ward (8 days).The cost of therapeutic failure was calculated as follows:<img src="260v39n12-13055460tab04.gif"></img>where v is the number of ambulatory visits; fr, the number of failures; cv, the unit cost of an ambulatory visit; em, the number of emergency room visits; cem, the unit cost of an emergency room visit; h, the number of hospitalizations; and cpw, the cost per day of a hospital stay on the pneumology ward (8 days).The costs corresponded to the year 2001. To facilitate comparison we have expressed all the costs in US dollars at mid-2002 exchange rates.To calculate the percentage of the various factors making up the direct costs of treatment of exacerbation, we took the sum of each country's costs and calculated the percent of the total for each determining factor: medical service, antibiotics, other pharmaceuticals, and failure, which included a subsequent ambulatory visit, emergency room visit, or hospitalization.ResultsThe countries for which we obtained data were Argentina, Brazil, Colombia, Ecuador, Mexico, Peru, and Venezuela. The costs of health care resources for each country are shown in Table 2. The marked variation in these costs was due to variations in health care systems, prices, level of economic development, and oscillating exchange rates between the home currency and the US dollar. The country with the highest cost per ambulatory visit was Peru ($124); the highest for an emergency room visit was Venezuela ($310.48); and the highest for hospitalization was Argentina ($3120). The cost of Spanish ambulatory service was slightly less due to the type of health care system, which significantly brings down the cost of such treatment.<img src="260v39n12-13055460tab05.gif"></img>Pharmacoeconomic EvaluationTo analyze resource consumption we calculated the cost of therapeutic failure for treating exacerbation during the initial 30 days of follow up. This cost was limited to 3 types of medical care: subsequent ambulatory visit, emergency room visit, and hospitalization. Consumption of resources in US dollars is shown in Table 3. The cost of therapeutic failure ranged from Columbia's $28, which represented 28.6% of the total cost of exacerbation, to Venezuela's $136, which represented 48% of the total cost of exacerbation. However, the highest cost percentage attributable to therapeutic failure was Ecuador's (59.3%). In comparison, it is noteworthy that therapeutic failure represented 62.8% of the total cost of exacerbation in Spain, due to a disproportionately high cost of hospital treatment in comparison to a low cost of ambulatory treatment in Spain, the difference being far greater than that seen in any of the Latin American countries studied.9<img src="260v39n12-13055460tab06.gif"></img>A breakdown of the costs for the Latin American countries shows that therapeutic failure accounts for the greatest part of the total cost, 51.9%; antibiotic treatment accounts for 19.7%; other pharmaceuticals administered, 16.3%; and the initial medical visit, 11.9% (Figure 2).<img src="260v39n12-13055460tab07.gif"></img>Figure 2. Distribution of the direct health care costs of treating patients with exacerbations.DiscussionThe present study is the first pharmacoeconomic analysis of COPD exacerbations in several Latin American countries. Cost analyses to orient strategies for optimizing the use of resources in Latin America are scant or nonexistent8 despite the increase in health care expenses, especially in those countries with weakened economies. In the present study the inclusion of data on various Latin American countries permits a comparative examination that may be useful for detecting inefficiencies in the systems.The first observation that emerges from our study is the unequal economic burden that medical acts generate in the various countries. Outstanding is Columbia's low mean cost per hospitalization due to therapeutic failure--only 28.6% of the total cost of exacerbations. Argentina, on the other hand, has a high mean cost for such hospitalizations. These differences may stem from multiple factors, such as variations in hospital use of technology, pharmaceuticals acquisition policies, salaries of medical personnel, and national economic circumstances, such as inflation rates and exchange rates with respect to the US dollar. Various combinations of these factors or other unidentified ones may explain the differences found between countries. It should be pointed out that we used the mean price in each country and that variations may be considerable depending on the type of centre (public or private); therefore, these results do not necessarily reflect a specific center but are rather to be viewed as an approximation of the group of medical centers within a given country.Evaluation of the direct cost for treating patients with exacerbated COPD reveals that the greatest expenditure derives from the treatment of patients for whom ambulatory treatment has failed. This observation was also documented in a previous Spanish study.9 Until recently few authors have looked at therapeutic failure in COPD exacerbations, although research from the early 1990s in the United Kingdom showed that up to 25% of the patients studied returned to their general practitioner within 1 month for subsequent consultation due to unsatisfactory clinical improvement and that most were prescribed a repeat course of antibiotics.13 Other studies have demonstrated that the failure rate for ambulatory treatment of COPD exacerbations varies between 15% and 25%.14 A Spanish study observed that increasingly impaired respiratory function, advanced age, and concomitant heart disease were the independent factors that were significantly associated with therapeutic failure.10 Furthermore, risk of hospitalization, the greatest cause of health care expenditure, has been related to a high number of previous exacerbations, increasingly impaired respiratory function, nonutilization of home oxygen therapy when prescribed, and heart disease.15,16 These factors, however, explain only a small proportion of the risk of hospitalization; the greatest proportion is probably due to infection.15Antibiotic treatment represents 19.7% of the cost of treating exacerbations. Although that percentage may seem high, we can keep it in proper perspective if we remember that therapeutic failure constitutes 51.9% of the cost of treating exacerbations. The marked difference indicates that there is plenty of opportunity for designing cost-effective strategies. If the rate of failure can be reduced, the total cost of exacerbations will decrease significantly as failure is the greatest determinant in the total cost. Reduction can be achieved using antibiotics with a higher acquisition price if they are shown to be more effective. This strategy has been tried in studies of the cost-effectiveness of exacerbation treatments, such as the one done in Canada with ciprofloxacin compared with other antibiotics.17 This study revealed that in a subgroup of severe patients with multiple risk factors, ciprofloxacin was a cost-effective alternative, probably due to the different spectrum of germs causing the exacerbations in these more severely ill patients.18 Therefore, the optimal choice of antibiotic, despite the occasionally reported greater initial cost, can save resources thanks to greater effectiveness and, consequently, fewer failures, which are more costly than the pharmaceutical itself.These data are already taken into account in various guidelines--such as that of the Latin American Thoracic Society (ALAT)--for the treatment of infectious exacerbations of COPD. The ALAT guidelines indicate the advantages of new antibiotics such as fluoroquinolones (moxifloxacin, gatifloxacin, and levofloxacin) over traditionally used antibiotics (tetracycline, co-trimoxazole, amoxicillin, erythromycin, clarithromycin).4 The advantages are a greater eradication capacity--especially against Haemophilus influenzae,19,20 more rapid bactericidal activity,20,21 and an adequate range of antibacterial activity.22 However, most clinical trials of antibiotics for treating exacerbations of chronic bronchitis and COPD are undertaken in order to register the product and obtain authorization from health care authorities. Such studies are therefore limited to demonstrating equivalence to traditionally used antibiotics.23 This means that there is still little evidence of the superiority of new antibiotics, although studies have been published indicating that new fluoroquinolones are better than traditionally used antibiotics in the treatment of respiratory infections.24,25 We can expect that future studies on COPD will focus on emphasizing the superiority of some antibiotics over others, and pharmacoeconomics is a sensitive method for detecting real benefits derived from a better, faster-acting antibacterial agent.6,26 Cost-effectiveness strategies should lead to a reduction of the economic burden of COPD, which has been calculated at a mean annual cost of $1876 per patient, of which 43.8% is derived from hospital care.27<hr></hr>The present study was funded by QF Bayer.Correspondence: Dr. M. Miravitlles. Servei de Pneumologia. Hospital Clínic. Villarroel, 170 (UVIR, esc. 2, planta 3). 08036 Barcelona. España. E-mail: <a href="mailto:marcm@clinic.ub.es" class="elsevierStyleCrossRefs"> marcm@clinic.ub.es</a>Manuscript received April 10, 2003. Accepted for publication July 29, 2003." "pdfFichero" => "260v39n12a13055460pdf001.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec191243" "palabras" => array:6 [ 0 => "Chronic bronchitis" 1 => "Chronic obstructive pulmonary disease (COPD)" 2 => "Exacerbations" 3 => "Antibiotics" 4 => "Costs" 5 => "Pharmacoeconomics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec191244" "palabras" => array:6 [ 0 => "Bronquitis crónica" 1 => "Enfermedad pulmonar obstructiva crónica (EPOC)" 2 => "Agudizaciones" 3 => "Antibióticos" 4 => "Costes" 5 => "Farmacoeconomía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:1 [ "resumen" => "Chronic obstructive pulmonary disease (COPD) and chronic bronchitis are highly prevalent diseases. Studies designed to analyze the economic impact of these diseases in Latin American countries have not previously been published. In the present study we analyzed the direct health care costs of treating patients with exacerbations of chronic bronchitis and COPD in Argentina, Brazil, Colombia, Ecuador, Mexico, Peru, and Venezuela, applying the real cost of drugs and medical acts in those 7 countries to the pattern of treatment and outcomes obtained from a study carried out in primary care settings in Spain. The mean direct health care cost ranged from US $98 in Colombia to $329 in Argentina. Most of the cost was related to failure of therapy, which accounted for 52% of the total cost of exacerbation, with the lowest rate in Colombia at 28.6% and the highest in Ecuador at 59.3% The cost of antibiotic therapy represented 19% of the total cost; the rest was owing to other drugs or medical visits. Exacerbations generate significant costs for health care systems. There are considerable variations related mainly to differences between systems. Antibiotic therapy represents a small part of the overall cost. The use of more effective antibiotics, if they can reduce failure rates, may be a cost-effective strategy." ] "es" => array:1 [ "resumen" => "La bronquitis crónica y la enfermedad pulmonar obstructiva crónica (EPOC) son enfermedades de elevada prevalencia. Los estudios destinados a conocer el impacto económico de estas enfermedades en países de Latinoamérica son inexistentes. En el presente trabajo se analizan los costes sanitarios directos originados por la atención a los pacientes con agudizaciones de la bronquitis crónica y la EPOC, mediante las estimaciones de tratamiento y evolución obtenidas a partir de un estudio realizado en el ámbito de la atención primaria en España, y aplicando los costes reales de los fármacos y las actuaciones sanitarias de los siguientes países: Argentina, Brasil, Colombia, Ecuador, México, Perú y Venezuela. El coste sanitario directo medio osciló desde los 98 dólares americanos en Colombia hasta los 329 de Argentina. La parte más importante del coste correspondió al fracaso terapéutico, que en conjunto supuso el 52% del coste de la agudización, con un mínimo del 28,6% para Colombia y un máximo del 59,3% para Ecuador. El coste del tratamiento antibiótico representó globalmente el 19% del coste total; el resto se debió a los otros fármacos y a la visita médica. Las agudizaciones originan un coste importante para los sistemas de salud. Existen importantes variaciones debidas sobre todo a diferencias en los sistemas sanitarios. El tratamiento antibiótico constituye una pequeña parte del coste global. La utilización de antibióticos más eficaces puede ser una estrategia coste-efectiva si logran reducir la tasa de fracasos." ] ] "multimedia" => array:14 [ 0 => array:8 [ "identificador" => "tbl1" "etiqueta" => "TABLE 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n12-13055460tab01.gif" "imagenAlto" => 334 "imagenAncho" => 384 "imagenTamanyo" => 12157 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Weights Assigned to Each of the Variables Included in the Present Pharmacoeconomic Analysis*" ] ] 1 => array:8 [ "identificador" => "tbl2" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n12-13055460tab02.gif" "imagenAlto" => 219 "imagenAncho" => 381 "imagenTamanyo" => 4086 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Plan of action for treating exacerbations. 1. Initiating treatment of the exacerbated patient. 2. During the 30 days following initiation no failure is produced; therefore, no presentation at ambulatory or hospital center is observed. 3. A failure is produced, implying that health care resources will be requested. 4. One option is ambulatory service. 5. Another option is hospital emergency room treatment. 6. Ambulatory service resolves the problem without hospitalization. 7. Ambulatory service leads to hospitalization. 8. Emergency room treatment resolves the problem without hospitalization. 9. Emergency room treatment leads to hospitalization." ] ] 2 => array:6 [ "identificador" => "tbl3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n12-13055460tab03.gif" "imagenAlto" => 42 "imagenAncho" => 348 "imagenTamanyo" => 2397 ] ] ] ] ] ] 3 => array:6 [ "identificador" => "tbl4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n12-13055460tab04.gif" "imagenAlto" => 32 "imagenAncho" => 345 "imagenTamanyo" => 2292 ] ] ] ] ] ] 4 => array:8 [ "identificador" => "tbl5" "etiqueta" => "TABLE 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n12-13055460tab05.gif" "imagenAlto" => 266 "imagenAncho" => 387 "imagenTamanyo" => 12205 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Cost in US Dollars of the Three Types of Medical Care in the Countries Studied*" ] ] 5 => array:8 [ "identificador" => "tbl6" "etiqueta" => "TABLE 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n12-13055460tab06.gif" "imagenAlto" => 253 "imagenAncho" => 378 "imagenTamanyo" => 10722 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Estimated Direct Health Care Cost in US Dollars for Treatment of Exacerbations and Therapeutic Failure" ] ] 6 => array:8 [ "identificador" => "tbl7" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:1 [ "tablaImagen" => array:1 [ 0 => array:4 [ "imagenFichero" => "260v39n12-13055460tab07.gif" "imagenAlto" => 376 "imagenAncho" => 380 "imagenTamanyo" => 6440 ] ] ] ] ] "descripcion" => array:1 [ "en" => "Distribution of the direct health care costs of treating patients with exacerbations." ] ] 7 => array:5 [ "identificador" => "tbl8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 8 => array:5 [ "identificador" => "tbl9" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 9 => array:5 [ "identificador" => "tbl10" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 10 => array:5 [ "identificador" => "tbl11" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 11 => array:5 [ "identificador" => "tbl12" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 12 => array:5 [ "identificador" => "tbl13" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] 13 => array:5 [ "identificador" => "tbl14" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:27 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Estudio epidemiológico de la EPOC en España (IBERPOC): reclutamiento y trabajo de campo." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Miravitlles M" 1 => "Sobradillo V" 2 => "Villasante C" 3 => "Gabriel R" 4 => "Masa JF" 5 => "Jiménez CA" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "1999" "volumen" => "35" "paginaInicial" => "152" "paginaFinal" => "8" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10330535" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Geographical variations in prevalence and underdiagnosis of COPD. Results of the IBERPOC multicentre epidemiological study." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Sobradillo V" 1 => "Miravitlles M" 2 => "Gabriel R" 3 => "Jiménez-Ruiz CA" 4 => "Villasante C" 5 => "Masa JF" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2000" "volumen" => "118" "paginaInicial" => "981" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11035667" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Prevalence and risk factors for chronic bronchitis in Pelotas, RS, Brazil: a population-based study." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Menezes AM.B" 1 => "Victoria CG" 2 => "Rigatto M." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "1994" "volumen" => "49" "paginaInicial" => "1217" "paginaFinal" => "21" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7878555" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Recomendaciones ALAT sobre exacerbación infecciosa de la EPOC." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Grupo de Trabajo de la Asociación Latinoamericana del Tórax (ALAT)." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2001" "volumen" => "37" "paginaInicial" => "349" "paginaFinal" => "57" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11562321" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Epidemiology of chronic obstructive pulmonary disease exacerbations." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Miravitlles M." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Pulm Med" "fecha" => "2002" "volumen" => "9" "paginaInicial" => "191" "paginaFinal" => "7" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Pharmacoeconomics of antibacterial treatment." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "Davey PG" 1 => "Malek MM" 2 => "Parker SE." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "PharmacoEconomics" "fecha" => "1992" "volumen" => "1" "paginaInicial" => "409" "paginaFinal" => "37" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10147022" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Treatment of chronic obstructive pulmonary disease and its exacerbations in general practice." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Miravitlles M" 1 => "Mayordomo C" 2 => "Artés T" 3 => "Sánchez-Agudo L" 4 => "Nicolau F" 5 => "Segú JL" 6 => "and the EOLO Group." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Respir Med" "fecha" => "1999" "volumen" => "93" "paginaInicial" => "173" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10464874" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "El coste de la enfermedad pulmonar obstructiva crónica en España. Opciones para una optimización de recursos." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "Miravitlles M" 1 => "Figueras M." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2001" "volumen" => "37" "paginaInicial" => "388" "paginaFinal" => "93" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11674939" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib9" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Pharmacoeconomic evaluation of acute exacerbations of chronic bronchitis and COPD." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Miravitlles M" 1 => "Murio C" 2 => "Guerrero T" 3 => "Gisbert R" 4 => "on behalf of the DAFNE Study Group." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2002" "volumen" => "121" "paginaInicial" => "1449" "paginaFinal" => "55" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12006427" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib10" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Factors associated with relapse after ambulatory treatment of acute exacerbations of chronic bronchitis. A prospective multicenter study in the community." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Miravitlles M" 1 => "Murio C" 2 => "Guerrero T" 3 => "on behalf of the DAFNE Study Group." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2001" "volumen" => "17" "paginaInicial" => "928" "paginaFinal" => "33" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11488328" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib11" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Hernández C" 1 => "Casas A" 2 => "Escarrabill J" 3 => "Alonso J" 4 => "Puig-Junoy J" 5 => "Farrero E" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2003" "volumen" => "21" "paginaInicial" => "58" "paginaFinal" => "67" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12570110" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib12" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Audit of acute admissions of COPD: standards of care and management in the hospital setting." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "Roberts CM" 1 => "Ryland I" 2 => "Lowe D" 3 => "Kelly Y" 4 => "Bucknall CE" 5 => "Pearson MG." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2001" "volumen" => "17" "paginaInicial" => "343" "paginaFinal" => "9" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11405509" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib13" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Prospective study of aetiology and outcome of adult lower respiratory tract infections in the community." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "MacFarlane JT" 1 => "Colville A" 2 => "Guion A" 3 => "MacFarlane RM" 4 => "Rose DH." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "1993" "volumen" => "341" "paginaInicial" => "511" "paginaFinal" => "4" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8094769" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib14" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "El fracaso en el tratamiento de las agudizaciones de la enfermedad pulmonar obstructiva crónica. Factores de riesgo e importancia clínica." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Miravitlles M." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2002" "volumen" => "119" "paginaInicial" => "304" "paginaFinal" => "14" ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib15" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "García-Aymerich J" 1 => "Monsó E" 2 => "Marrades RM" 3 => "Escarrabill J" 4 => "Félez MA" 5 => "Sunyer J" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/ajrccm.164.6.2006012" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2001" "volumen" => "164" "paginaInicial" => "1002" "paginaFinal" => "7" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11587986" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib16" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Factors associated with increased risk of exacerbation and hospital admission in a cohort of ambulatory COPD patients: a multiple logistic regression analysis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Miravitlles M" 1 => "Guerrero T" 2 => "Mayordomo C" 3 => "Sánchez-Agudo L" 4 => "Nicolau F" 5 => "Segú JL" 6 => "on behalf of the EOLO Group." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "67462" "Revista" => array:6 [ "tituloSerie" => "Respiration" "fecha" => "2000" "volumen" => "67" "paginaInicial" => "495" "paginaFinal" => "501" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11070451" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib17" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "A 1-year community-based health economic study of ciprofloxacin vs usual antibiotic treatment in acute exacerbations of chronic bronchitis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Grossman R" 1 => "Mukherjee J" 2 => "Vaughan D" 3 => "Eastwood C" 4 => "Cook R" 5 => "La-Forge J" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1998" "volumen" => "113" "paginaInicial" => "131" "paginaFinal" => "41" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9440580" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib18" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Relationship between bacterial flora in sputum and functional impairment in patients with acute exacerbations of COPD." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Miravitlles M" 1 => "Espinosa C" 2 => "Fernández-Laso E" 3 => "Martos JA" 4 => "Maldonado JA" 5 => "Gallego M" 6 => "and Study Group of Bacterial Infection in COPD." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "1999" "volumen" => "116" "paginaInicial" => "40" "paginaFinal" => "6" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10424501" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib19" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Five day moxifloxacin therapy compared with 7 day clarithromycin therapy for the treatment of acute exacerbations of chronic bronchitis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Wilson R" 1 => "Kubin R" 2 => "Ballin I" 3 => "Deppermann KM" 4 => "Bassaris HP" 5 => "Leophonte P" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Antimicrob Chemother" "fecha" => "1999" "volumen" => "44" "paginaInicial" => "501" "paginaFinal" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10588312" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib20" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "The safety and efficacy of short course (5-day) moxifloxacin vs. azithromycin in the treatment of patients with acute exacerbation of chronic bronchitis." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "DeAbate CA" 1 => "Mathew CP" 2 => "Warner JH" 3 => "Heyd A" 4 => "Church D." ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/rmed.2000.0927" "Revista" => array:6 [ "tituloSerie" => "Respir Med" "fecha" => "2000" "volumen" => "94" "paginaInicial" => "1029" "paginaFinal" => "37" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11127487" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib21" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "The efficacy of moxifloxacin in acute exacerbations of chronic bronchitis; a Spanish physician and patient experience." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Miravitlles M" 1 => "Ros F" 2 => "Cobos A" 3 => "Kubin R" 4 => "Tillotson G." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Int J Clin Pract" "fecha" => "2001" "volumen" => "55" "paginaInicial" => "437" "paginaFinal" => "41" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11594251" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib22" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "In vitro activity of BAY 12-8039, a new fluoroquinolone." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Woodcock JM" 1 => "Andrews JM" 2 => "Boswell FJ" 3 => "Brenwald NP" 4 => "Wise R." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Antimicrob Agents Chemother" "fecha" => "1997" "volumen" => "41" "paginaInicial" => "101" "paginaFinal" => "6" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8980763" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib23" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Designing future clinical trials for acute exacerbations of chronic bronchitis. In: Allegra L, Blasi F, editors. Mechanisms and management of COPD exacerbations. Milan: Springer-Verlag" "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Miravitlles M." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:4 [ "titulo" => "Designing future clinical trials for acute exacerbations of chronic bronchitis. In: Allegra L, Blasi F, editors. Mechanisms and management of COPD exacerbations. Milan: Springer-Verlag" "fecha" => "2000" "paginaInicial" => "88" "paginaFinal" => "99" ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib24" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "A randomized controlled trial of sequential intravenous (i.v.) and oral moxifloxacin compared with sequential i.v. and oral co-amoxiclav with or without clarithromycin in patients with community-acquired pneumonia requiring initial parenteral treatment." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:7 [ 0 => "Finch R" 1 => "Schürmann D" 2 => "Collins O" 3 => "Kubin R" 4 => "McGivern J" 5 => "Bobbaers H" 6 => "et al." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Antimicrob Agents Chemother" "fecha" => "2002" "volumen" => "46" "paginaInicial" => "1746" "paginaFinal" => "54" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12019085" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib25" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Speed of recovery from acute exacerbations of COPD after treatment with moxifloxacin: results of a two-year study." "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:8 [ 0 => "Miravitlles M" 1 => "Zalacain R" 2 => "Murio C" 3 => "Álvarez-Sala JL" 4 => "Masa JF" 5 => "Verea H" 6 => "et al" 7 => "on behalf of the IMPAC Study Group." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Drug Invest" "fecha" => "2003" "volumen" => "23" "paginaInicial" => "439" "paginaFinal" => "50" ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib26" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Farmacoeconomía: el cálculo de la eficiencia." "idioma" => "es" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "Sacristán JA" 1 => "Soto J" 2 => "Reviriego J" 3 => "Galende I." ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "1994" "volumen" => "103" "paginaInicial" => "143" "paginaFinal" => "9" ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib27" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "referenciaCompleta" => "Costs of chronic bronchitis and COPD. A one year follow-up study. Chest 2003;123:784-91. Arch Bronconeumol 2003;39(12):549-53 553" "contribucion" => array:1 [ 0 => array:3 [ "titulo" => "Costs of chronic bronchitis and COPD. A one year follow-up study. Chest 2003;123:784-91. Arch Bronconeumol 2003;39(12):549-53 553" "idioma" => "en" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Miravitlles M" 1 => "Murio C" 2 => "Guerrero T" 3 => "Gisbert R" 4 => "on behalf of the DAFNE Study Group." ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000003900000012/v0_201307090853/13055460/v0_201307090853/en/main.assets" "Apartado" => array:4 [ "identificador" => "14570" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Original papers" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000003900000012/v0_201307090853/13055460/v0_201307090853/en/260v39n12a13055460pdf001.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13055460?idApp=UINPBA00003Z"]

Statistics

Estudio farmacoeconómico del tratamiento antibiótico de las agudizaciones de la bronquitis crónica y la EPOC en Latinoamérica

M. Miravitllesa, JR. Jardimb, T. Zittoc, JE. Rodriguesd, H. Lópezc

a Servei de Pneumologia, Institut Clínic de Pneumologia i Cirurgia Toràcica (IDIBAPS), Hospital Clínic, Barcelona, Spain.

b Servicio de Neumología y Grupo de Farmacoeconomía en EPOC, Universidade Federal de São Paulo, São Paulo, Brazil.

c Centro de Infectología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina.

d Grupo de Farmacoeconomía en EPOC, Universidade Federal de São Paulo, São Paulo, Brazil.

Read

10138

Times
was read the article

3571

Total PDF

6567

Total HTML

Share statistics

 array:19 [
  "pii" => "13055460"
  "issn" => "15792129"
  "estado" => "S300"
  "fechaPublicacion" => "2003-12-01"
  "documento" => "article"
  "crossmark" => 0
  "subdocumento" => "fla"
  "cita" => "Arch Bronconeumol. 2003;39:549-53"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 5699
    "formatos" => array:3 [
      "EPUB" => 137
      "HTML" => 3757
      "PDF" => 1805
    ]
  ]
  "itemSiguiente" => array:15 [
    "pii" => "13055461"
    "issn" => "15792129"
    "estado" => "S300"
    "fechaPublicacion" => "2003-12-01"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "fla"
    "cita" => "Arch Bronconeumol. 2003;39:554-8"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 6961
      "formatos" => array:3 [
        "EPUB" => 153
        "HTML" => 5682
        "PDF" => 1126
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "titulo" => "Prevalence of Chronic Obstructive Pulmonary Disease and Risk Factors in Smokers and Ex-Smokers"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "554"
          "paginaFinal" => "558"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Prevalencia y factores de riesgo de EPOC en fumadores y ex fumadores"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "JI Ja&#233;n D&#237;az, C de Castro Mesa, G Gont&#225;n, MJ Salamanca, F L&#243;pez de Castro"
          "autores" => array:5 [
            0 => array:2 [
              "Iniciales" => "JI"
              "apellidos" => "Ja&#233;n D&#237;az"
            ]
            1 => array:2 [
              "Iniciales" => "C"
              "apellidos" => "de Castro Mesa"
            ]
            2 => array:2 [
              "Iniciales" => "G"
              "apellidos" => "Gont&#225;n"
            ]
            3 => array:2 [
              "Iniciales" => "MJ"
              "apellidos" => "Salamanca"
            ]
            4 => array:2 [
              "Iniciales" => "F"
              "apellidos" => "L&#243;pez de Castro"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13055461?idApp=UINPBA00003Z"
    "url" => "/15792129/0000003900000012/v0_201307090853/13055461/v0_201307090853/en/main.assets"
  ]
  "itemAnterior" => array:15 [
    "pii" => "13055459"
    "issn" => "15792129"
    "estado" => "S300"
    "fechaPublicacion" => "2003-12-01"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "fla"
    "cita" => "Arch Bronconeumol. 2003;39:544-8"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 5183
      "formatos" => array:3 [
        "EPUB" => 146
        "HTML" => 4091
        "PDF" => 946
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "titulo" => "Comparison Between Automatic and Manual Analysis in the Diagnosis of Obstructive Sleep Apnea-Hypopnea Syndrome"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "544"
          "paginaFinal" => "548"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Comparaci&#243;n entre el an&#225;lisis autom&#225;tico y manual de la polisomnograf&#237;a convencional en el diagn&#243;stico del s&#237;ndrome de apnea-hipopnea obstructiva del sue&#241;o"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "B Barreiro, G Badosa, S Quintana, L Esteban, JL Heredia"
          "autores" => array:5 [
            0 => array:2 [
              "Iniciales" => "B"
              "apellidos" => "Barreiro"
            ]
            1 => array:2 [
              "Iniciales" => "G"
              "apellidos" => "Badosa"
            ]
            2 => array:2 [
              "Iniciales" => "S"
              "apellidos" => "Quintana"
            ]
            3 => array:2 [
              "Iniciales" => "L"
              "apellidos" => "Esteban"
            ]
            4 => array:2 [
              "Iniciales" => "JL"
              "apellidos" => "Heredia"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13055459?idApp=UINPBA00003Z"
    "url" => "/15792129/0000003900000012/v0_201307090853/13055459/v0_201307090853/en/main.assets"
  ]
  "en" => array:14 [
    "idiomaDefecto" => true
    "titulo" => "Pharmacoeconomic Study of Antibiotic Therapy for Acute Exacerbations of Chronic Bronchitis and Chronic Obstructive Pulmonary Disease in Latin America"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "549"
        "paginaFinal" => "553"
      ]
    ]
    "autores" => array:1 [
      0 => array:3 [
        "autoresLista" => "M Miravitlles, JR Jardim, T Zitto, JE Rodrigues, H L&#243;pez"
        "autores" => array:5 [
          0 => array:3 [
            "Iniciales" => "M"
            "apellidos" => "Miravitlles"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          1 => array:3 [
            "Iniciales" => "JR"
            "apellidos" => "Jardim"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "affb"
              ]
            ]
          ]
          2 => array:3 [
            "Iniciales" => "T"
            "apellidos" => "Zitto"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "affc"
              ]
            ]
          ]
          3 => array:3 [
            "Iniciales" => "JE"
            "apellidos" => "Rodrigues"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "affd"
              ]
            ]
          ]
          4 => array:3 [
            "Iniciales" => "H"
            "apellidos" => "L&#243;pez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "affc"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:4 [
          0 => array:3 [
            "entidad" => "Servei de Pneumologia, Institut Clínic de Pneumologia i Cirurgia Toràcica (IDIBAPS), Hospital Clínic, Barcelona, Spain."
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "affa"
          ]
          1 => array:3 [
            "entidad" => "Servicio de Neumología y Grupo de Farmacoeconomía en EPOC, Universidade Federal de São Paulo, São Paulo, Brazil."
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "affb"
          ]
          2 => array:3 [
            "entidad" => "Centro de Infectología, Facultad de Medicina, Universidad de Buenos Aires, Buenos Aires, Argentina."
            "etiqueta" => "<span class="elsevierStyleSup">c</span>"
            "identificador" => "affc"
          ]
          3 => array:3 [
            "entidad" => "Grupo de Farmacoeconomía en EPOC, Universidade Federal de São Paulo, São Paulo, Brazil."
            "etiqueta" => "<span class="elsevierStyleSup">d</span>"
            "identificador" => "affd"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Estudio farmacoecon&#243;mico del tratamiento antibi&#243;tico de las agudizaciones de la bronquitis cr&#243;nica y la EPOC en Latinoam&#233;rica"
      ]
    ]
    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction</span></p><p class="elsevierStylePara">Chronic respiratory disease&#44; especially chronic bronchitis and chronic obstructive pulmonary disease &#40;COPD&#41;&#44; is one of the most common causes of demand for primary health care&#46; Recent studies in Spain estimate that 8&#37; to 10&#37; of the population over 40 years of age may have COPD<span class="elsevierStyleSup">1&#44;2</span> and that the percentage may be as high as 20&#37; for men over 65 years of age&#46;<span class="elsevierStyleSup">2</span> A Brazilian population study revealed a prevalence of chronic bronchitis of 12&#46;7&#37; of those over 40 years of age&#46;<span class="elsevierStyleSup">3</span> Epidemiological studies have not been published for many Latin American countries&#44; but mortality statistics show COPD to be one of the most common causes of death&#44; surpassed only by cardiovascular diseases and cancer&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">Respiratory symptoms may increase suddenly in both chronic bronchitis and COPD&#44; producing the crises we know as exacerbations&#44; the majority of which stem from infection&#46;<span class="elsevierStyleSup">5</span> Key to treating infectious exacerbations of chronic bronchitis and COPD is the administration of antibiotics with adequate ranges of action&#44; easy dosing regimens&#44; and reasonable cost&#46; Furthermore&#44; evaluation of the results of different antibiotics used in treating exacerbations is necessary in order to establish the most cost-effective options&#46; The dilemma in recent years of ever-increasing health care costs paralleled by necessarily limited resources calls for economic evaluation of pharmacological treatments&#46;<span class="elsevierStyleSup">6</span> Such an evaluation applied to chronic bronchitis and COPD is pivotal for social and health care management as&#44; according to a recent study&#44; COPD patients suffer a mean of 2 exacerbations per year&#44; 90&#37; of which are treated with antibiotics and 10&#37; of which require hospital admission&#46;<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">In a context such as the Latin American one&#44; pharmacoeconomics acquires special relevance due to the difficult economic situation in some countries&#46; Identification of the factors determining health care costs is prerequisite to establishing strategies for more efficient use of resources&#46;<span class="elsevierStyleSup">8</span> The present study estimates the direct health care costs derived from treating exacerbations of chronic bronchitis and COPD in various Latin American countries using economic data obtained in each country and the results of a recent Spanish pharmacoeconomic study&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Method</span></p><p class="elsevierStylePara">The present pharmacoeconomic study uses data from an analysis of the direct health care costs of treating patients with chronic bronchitis or exacerbated COPD&#46; Based on these data&#44; estimates of costs were calculated for various countries in Latin America--Argentina&#44; Brazil&#44; Columbia&#44; Ecuador&#44; Mexico&#44; Peru&#44; and Venezuela--factoring in the real costs of pharmaceuticals and health care expenses in each country&#46;</p><p class="elsevierStylePara">For our analysis we started with a Spanish study on the use of health care resources in primary treatment of exacerbations of chronic bronchitis and COPD in Spain&#46;<span class="elsevierStyleSup">9</span> The study included a description of the treatments used&#44; the percentage of therapeutic failure&#44; and the percentages of subsequent medical visits&#44; hospital emergency room treatment&#44; and hospitalizations involved in treating patients with exacerbations &#40;Table 1&#41;&#46; Each pharmaceutical was given a weight derived from the percentage of its use in treating the exacerbations&#59; similarly&#44; subsequent health care acts were weighted according to their frequency&#46; Due to the absence of studies on the use of resources for treating exacerbations of chronic bronchitis and COPD in Latin America&#44; we applied the same weights &#40;Table 1&#41; for calculating the costs in the Latin American countries studied&#46; That is&#44; the global rate of failure in Latin America would be considered as 21&#37;&#59; emergency room visits&#44; 6&#46;7&#37;&#59; and hospitalizations&#44; 3&#46;4&#37;&#46;<span class="elsevierStyleSup">9&#44;10</span> These assumed rates may differ considerably from certain local health care rates&#59; however&#44; applied to each country&#44; they allow for a comparison of exacerbation costs and therapeutic failure derived from the costs of the various national health care resources without the interference of factors such as patient characteristics or disease management&#46;</p><p class="elsevierStylePara"><img src="260v39n12-13055460tab01.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Pharmacoeconomic Analysis</span></p><p class="elsevierStylePara">The costs used in calculating the global rates were the so-called direct costs--those related to the consumption of health care system resources--in order to ascertain variations in the consumption of system resources&#46; Not included&#44; for example&#44; were costs incurred by patients for transportation to health care centers or the loss of time involved&#46; In other words&#44; the consumption of resources evaluated was the cost of treating the exacerbation and the cost of failure of this treatment&#59; the latter cost was limited to the following 3 factors&#58; subsequent ambulatory visit&#44; emergency room visit&#44; or hospital stay&#46;</p><p class="elsevierStylePara">The diagram &#40;Figure 1&#41; was the same as that used in recent studies on health care costs of treating exacerbation of chronic bronchitis and COPD&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara"><img src="260v39n12-13055460tab02.gif"></img></p><p class="elsevierStylePara">Figure 1&#46; Plan of action for treating exacerbations&#46; 1&#46; Initiating treatment of the exacerbated patient&#46; 2&#46; During the 30 days following initiation no failure is produced&#59; therefore&#44; no presentation at ambulatory or hospital center is observed&#46; 3&#46; A failure is produced&#44; implying that health care resources will be requested&#46; 4&#46; One option is ambulatory service&#46; 5&#46; Another option is hospital emergency room treatment&#46; 6&#46; Ambulatory service resolves the problem without hospitalization&#46; 7&#46; Ambulatory service leads to hospitalization&#46; 8&#46; Emergency room treatment resolves the problem without hospitalization&#46; 9&#46; Emergency room treatment leads to hospitalization&#46;</p><p class="elsevierStylePara">The costs included in our analysis were the following&#58; <span class="elsevierStyleItalic">a&#41;</span> the costs of each treatment option included in point 1 of Figure 1&#59; <span class="elsevierStyleItalic">b&#41;</span> the cost of the ambulatory visit&#59; <span class="elsevierStyleItalic">c&#41;</span> the cost of the emergency room visit&#44; and <span class="elsevierStyleItalic">d&#41;</span> the cost of the hospital stay&#46;</p><p class="elsevierStylePara">To calculate the costs of the ambulatory visits&#44; emergency room visits&#44; and hospital stays&#44; we used the official costs provided by health care authorities or obtained from public referral health care centers&#46; In the case of emergency room visits we included the cost of a single chest x-ray and a hemogram&#46; When there was a lack of information on the mean length of hospital stay per exacerbation of COPD in the various countries&#44; we calculated for 8 days&#44; in accordance with published studies&#46;<span class="elsevierStyleSup">11&#44;12</span> The cost of pharmacological treatment was obtained from the official registered prices of the active ingredients of pharmaceuticals available in each country&#46;</p><p class="elsevierStylePara">The equation for obtaining the final cost-per-patient result was the following&#58;</p><p class="elsevierStylePara"><img src="260v39n12-13055460tab03.gif"></img></p><p class="elsevierStylePara">where <span class="elsevierStyleItalic">v</span> is the number of ambulatory visits&#59; <span class="elsevierStyleItalic">p</span>&#44; the number of patients&#59; <span class="elsevierStyleItalic">c<span class="elsevierStyleInf">v</span></span>&#44; the unit cost of an ambulatory visit&#59; <span class="elsevierStyleItalic">e<span class="elsevierStyleInf">m</span></span>&#44; the number of emergency room visits&#59; <span class="elsevierStyleItalic">c<span class="elsevierStyleInf">em</span></span>&#44; the unit cost of an emergency room visit&#59; <span class="elsevierStyleItalic">h</span>&#44; the number of hospitalizations&#59; and <span class="elsevierStyleItalic"> c<span class="elsevierStyleInf">pw</span></span>&#44; the cost per day of a hospital stay on the pneumology ward &#40;8 days&#41;&#46;</p><p class="elsevierStylePara">The cost of therapeutic failure was calculated as follows&#58;</p><p class="elsevierStylePara"><img src="260v39n12-13055460tab04.gif"></img></p><p class="elsevierStylePara">where <span class="elsevierStyleItalic">v</span> is the number of ambulatory visits&#59; <span class="elsevierStyleItalic">f<span class="elsevierStyleInf">r</span></span>&#44; the number of failures&#59; <span class="elsevierStyleItalic">c<span class="elsevierStyleInf">v</span></span>&#44; the unit cost of an ambulatory visit&#59; <span class="elsevierStyleItalic">e<span class="elsevierStyleInf">m</span></span>&#44; the number of emergency room visits&#59; <span class="elsevierStyleItalic">c<span class="elsevierStyleInf">em</span></span>&#44; the unit cost of an emergency room visit&#59; <span class="elsevierStyleItalic">h</span>&#44; the number of hospitalizations&#59; and <span class="elsevierStyleItalic"> c<span class="elsevierStyleInf">pw</span></span>&#44; the cost per day of a hospital stay on the pneumology ward &#40;8 days&#41;&#46;</p><p class="elsevierStylePara">The costs corresponded to the year 2001&#46; To facilitate comparison we have expressed all the costs in US dollars at mid-2002 exchange rates&#46;</p><p class="elsevierStylePara">To calculate the percentage of the various factors making up the direct costs of treatment of exacerbation&#44; we took the sum of each country&#39;s costs and calculated the percent of the total for each determining factor&#58; medical service&#44; antibiotics&#44; other pharmaceuticals&#44; and failure&#44; which included a subsequent ambulatory visit&#44; emergency room visit&#44; or hospitalization&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Results</span></p><p class="elsevierStylePara">The countries for which we obtained data were Argentina&#44; Brazil&#44; Colombia&#44; Ecuador&#44; Mexico&#44; Peru&#44; and Venezuela&#46; The costs of health care resources for each country are shown in Table 2&#46; The marked variation in these costs was due to variations in health care systems&#44; prices&#44; level of economic development&#44; and oscillating exchange rates between the home currency and the US dollar&#46; The country with the highest cost per ambulatory visit was Peru &#40;&#36;124&#41;&#59; the highest for an emergency room visit was Venezuela &#40;&#36;310&#46;48&#41;&#59; and the highest for hospitalization was Argentina &#40;&#36;3120&#41;&#46; The cost of Spanish ambulatory service was slightly less due to the type of health care system&#44; which significantly brings down the cost of such treatment&#46;</p><p class="elsevierStylePara"><img src="260v39n12-13055460tab05.gif"></img></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Pharmacoeconomic Evaluation</span></p><p class="elsevierStylePara">To analyze resource consumption we calculated the cost of therapeutic failure for treating exacerbation during the initial 30 days of follow up&#46; This cost was limited to 3 types of medical care&#58; subsequent ambulatory visit&#44; emergency room visit&#44; and hospitalization&#46; Consumption of resources in US dollars is shown in Table 3&#46; The cost of therapeutic failure ranged from Columbia&#39;s &#36;28&#44; which represented 28&#46;6&#37; of the total cost of exacerbation&#44; to Venezuela&#39;s &#36;136&#44; which represented 48&#37; of the total cost of exacerbation&#46; However&#44; the highest cost percentage attributable to therapeutic failure was Ecuador&#39;s &#40;59&#46;3&#37;&#41;&#46; In comparison&#44; it is noteworthy that therapeutic failure represented 62&#46;8&#37; of the total cost of exacerbation in Spain&#44; due to a disproportionately high cost of hospital treatment in comparison to a low cost of ambulatory treatment in Spain&#44; the difference being far greater than that seen in any of the Latin American countries studied&#46;<span class="elsevierStyleSup">9</span></p><p class="elsevierStylePara"><img src="260v39n12-13055460tab06.gif"></img></p><p class="elsevierStylePara">A breakdown of the costs for the Latin American countries shows that therapeutic failure accounts for the greatest part of the total cost&#44; 51&#46;9&#37;&#59; antibiotic treatment accounts for 19&#46;7&#37;&#59; other pharmaceuticals administered&#44; 16&#46;3&#37;&#59; and the initial medical visit&#44; 11&#46;9&#37; &#40;Figure 2&#41;&#46;</p><p class="elsevierStylePara"><img src="260v39n12-13055460tab07.gif"></img></p><p class="elsevierStylePara">Figure 2&#46; Distribution of the direct health care costs of treating patients with exacerbations&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">The present study is the first pharmacoeconomic analysis of COPD exacerbations in several Latin American countries&#46; Cost analyses to orient strategies for optimizing the use of resources in Latin America are scant or nonexistent<span class="elsevierStyleSup">8</span> despite the increase in health care expenses&#44; especially in those countries with weakened economies&#46; In the present study the inclusion of data on various Latin American countries permits a comparative examination that may be useful for detecting inefficiencies in the systems&#46;</p><p class="elsevierStylePara">The first observation that emerges from our study is the unequal economic burden that medical acts generate in the various countries&#46; Outstanding is Columbia&#39;s low mean cost per hospitalization due to therapeutic failure--only 28&#46;6&#37; of the total cost of exacerbations&#46; Argentina&#44; on the other hand&#44; has a high mean cost for such hospitalizations&#46; These differences may stem from multiple factors&#44; such as variations in hospital use of technology&#44; pharmaceuticals acquisition policies&#44; salaries of medical personnel&#44; and national economic circumstances&#44; such as inflation rates and exchange rates with respect to the US dollar&#46; Various combinations of these factors or other unidentified ones may explain the differences found between countries&#46; It should be pointed out that we used the mean price in each country and that variations may be considerable depending on the type of centre &#40;public or private&#41;&#59; therefore&#44; these results do not necessarily reflect a specific center but are rather to be viewed as an approximation of the group of medical centers within a given country&#46;</p><p class="elsevierStylePara">Evaluation of the direct cost for treating patients with exacerbated COPD reveals that the greatest expenditure derives from the treatment of patients for whom ambulatory treatment has failed&#46; This observation was also documented in a previous Spanish study&#46;<span class="elsevierStyleSup">9</span> Until recently few authors have looked at therapeutic failure in COPD exacerbations&#44; although research from the early 1990s in the United Kingdom showed that up to 25&#37; of the patients studied returned to their general practitioner within 1 month for subsequent consultation due to unsatisfactory clinical improvement and that most were prescribed a repeat course of antibiotics&#46;<span class="elsevierStyleSup">13</span> Other studies have demonstrated that the failure rate for ambulatory treatment of COPD exacerbations varies between 15&#37; and 25&#37;&#46;<span class="elsevierStyleSup">14</span> A Spanish study observed that increasingly impaired respiratory function&#44; advanced age&#44; and concomitant heart disease were the independent factors that were significantly associated with therapeutic failure&#46;<span class="elsevierStyleSup">10</span> Furthermore&#44; risk of hospitalization&#44; the greatest cause of health care expenditure&#44; has been related to a high number of previous exacerbations&#44; increasingly impaired respiratory function&#44; nonutilization of home oxygen therapy when prescribed&#44; and heart disease&#46;<span class="elsevierStyleSup">15&#44;16</span> These factors&#44; however&#44; explain only a small proportion of the risk of hospitalization&#59; the greatest proportion is probably due to infection&#46;<span class="elsevierStyleSup">15</span></p><p class="elsevierStylePara">Antibiotic treatment represents 19&#46;7&#37; of the cost of treating exacerbations&#46; Although that percentage may seem high&#44; we can keep it in proper perspective if we remember that therapeutic failure constitutes 51&#46;9&#37; of the cost of treating exacerbations&#46; The marked difference indicates that there is plenty of opportunity for designing cost-effective strategies&#46; If the rate of failure can be reduced&#44; the total cost of exacerbations will decrease significantly as failure is the greatest determinant in the total cost&#46; Reduction can be achieved using antibiotics with a higher acquisition price if they are shown to be more effective&#46; This strategy has been tried in studies of the cost-effectiveness of exacerbation treatments&#44; such as the one done in Canada with ciprofloxacin compared with other antibiotics&#46;<span class="elsevierStyleSup">17</span> This study revealed that in a subgroup of severe patients with multiple risk factors&#44; ciprofloxacin was a cost-effective alternative&#44; probably due to the different spectrum of germs causing the exacerbations in these more severely ill patients&#46;<span class="elsevierStyleSup">18</span> Therefore&#44; the optimal choice of antibiotic&#44; despite the occasionally reported greater initial cost&#44; can save resources thanks to greater effectiveness and&#44; consequently&#44; fewer failures&#44; which are more costly than the pharmaceutical itself&#46;</p><p class="elsevierStylePara">These data are already taken into account in various guidelines--such as that of the Latin American Thoracic Society &#40;ALAT&#41;--for the treatment of infectious exacerbations of COPD&#46; The ALAT guidelines indicate the advantages of new antibiotics such as fluoroquinolones &#40;moxifloxacin&#44; gatifloxacin&#44; and levofloxacin&#41; over traditionally used antibiotics &#40;tetracycline&#44; co-trimoxazole&#44; amoxicillin&#44; erythromycin&#44; clarithromycin&#41;&#46;<span class="elsevierStyleSup">4</span> The advantages are a greater eradication capacity--especially against <span class="elsevierStyleItalic">Haemophilus influenzae</span>&#44;<span class="elsevierStyleSup">19&#44;20</span> more rapid bactericidal activity&#44;<span class="elsevierStyleSup">20&#44;21</span> and an adequate range of antibacterial activity&#46;<span class="elsevierStyleSup">22</span> However&#44; most clinical trials of antibiotics for treating exacerbations of chronic bronchitis and COPD are undertaken in order to register the product and obtain authorization from health care authorities&#46; Such studies are therefore limited to demonstrating equivalence to traditionally used antibiotics&#46;<span class="elsevierStyleSup">23</span> This means that there is still little evidence of the superiority of new antibiotics&#44; although studies have been published indicating that new fluoroquinolones are better than traditionally used antibiotics in the treatment of respiratory infections&#46;<span class="elsevierStyleSup">24&#44;25</span> We can expect that future studies on COPD will focus on emphasizing the superiority of some antibiotics over others&#44; and pharmacoeconomics is a sensitive method for detecting real benefits derived from a better&#44; faster-acting antibacterial agent&#46;<span class="elsevierStyleSup">6&#44;26</span> Cost-effectiveness strategies should lead to a reduction of the economic burden of COPD&#44; which has been calculated at a mean annual cost of &#36;1876 per patient&#44; of which 43&#46;8&#37; is derived from hospital care&#46;<span class="elsevierStyleSup">27</span></p><hr></hr><p class="elsevierStylePara">The present study was funded by QF Bayer&#46;</p><p class="elsevierStylePara">Correspondence&#58; Dr&#46; M&#46; Miravitlles&#46;<br></br> Servei de Pneumologia&#46; Hospital Cl&#237;nic&#46;<br></br> Villarroel&#44; 170 &#40;UVIR&#44; esc&#46; 2&#44; planta 3&#41;&#46; 08036 Barcelona&#46; Espa&#241;a&#46;<br></br> E-mail&#58; <a href="mailto&#58;marcm&#64;clinic&#46;ub&#46;es" class="elsevierStyleCrossRefs"> marcm&#64;clinic&#46;ub&#46;es</a></p><p class="elsevierStylePara">Manuscript received April 10&#44; 2003&#46; Accepted for publication July 29&#44; 2003&#46;</p>"
    "pdfFichero" => "260v39n12a13055460pdf001.pdf"
    "tienePdf" => true
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec191243"
          "palabras" => array:6 [
            0 => "Chronic bronchitis"
            1 => "Chronic obstructive pulmonary disease &#40;COPD&#41;"
            2 => "Exacerbations"
            3 => "Antibiotics"
            4 => "Costs"
            5 => "Pharmacoeconomics"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec191244"
          "palabras" => array:6 [
            0 => "Bronquitis cr&#243;nica"
            1 => "Enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;"
            2 => "Agudizaciones"
            3 => "Antibi&#243;ticos"
            4 => "Costes"
            5 => "Farmacoeconom&#237;a"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:1 [
        "resumen" => "Chronic obstructive pulmonary disease &#40;COPD&#41; and chronic bronchitis are highly prevalent diseases&#46; Studies designed to analyze the economic impact of these diseases in Latin American countries have not previously been published&#46; In the present study we analyzed the direct health care costs of treating patients with exacerbations of chronic bronchitis and COPD in Argentina&#44; Brazil&#44; Colombia&#44; Ecuador&#44; Mexico&#44; Peru&#44; and Venezuela&#44; applying the real cost of drugs and medical acts in those 7 countries to the pattern of treatment and outcomes obtained from a study carried out in primary care settings in Spain&#46; The mean direct health care cost ranged from US &#36;98 in Colombia to &#36;329 in Argentina&#46; Most of the cost was related to failure of therapy&#44; which accounted for 52&#37; of the total cost of exacerbation&#44; with the lowest rate in Colombia at 28&#46;6&#37; and the highest in Ecuador at 59&#46;3&#37; The cost of antibiotic therapy represented 19&#37; of the total cost&#59; the rest was owing to other drugs or medical visits&#46; Exacerbations generate significant costs for health care systems&#46; There are considerable variations related mainly to differences between systems&#46; Antibiotic therapy represents a small part of the overall cost&#46; The use of more effective antibiotics&#44; if they can reduce failure rates&#44; may be a cost-effective strategy&#46;"
      ]
      "es" => array:1 [
        "resumen" => "La bronquitis cr&#243;nica y la enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41; son enfermedades de elevada prevalencia&#46; Los estudios destinados a conocer el impacto econ&#243;mico de estas enfermedades en pa&#237;ses de Latinoam&#233;rica son inexistentes&#46; En el presente trabajo se analizan los costes sanitarios directos originados por la atenci&#243;n a los pacientes con agudizaciones de la bronquitis cr&#243;nica y la EPOC&#44; mediante las estimaciones de tratamiento y evoluci&#243;n obtenidas a partir de un estudio realizado en el &#225;mbito de la atenci&#243;n primaria en Espa&#241;a&#44; y aplicando los costes reales de los f&#225;rmacos y las actuaciones sanitarias de los siguientes pa&#237;ses&#58; Argentina&#44; Brasil&#44; Colombia&#44; Ecuador&#44; M&#233;xico&#44; Per&#250; y Venezuela&#46; El coste sanitario directo medio oscil&#243; desde los 98 d&#243;lares americanos en Colombia hasta los 329 de Argentina&#46; La parte m&#225;s importante del coste correspondi&#243; al fracaso terap&#233;utico&#44; que en conjunto supuso el 52&#37; del coste de la agudizaci&#243;n&#44; con un m&#237;nimo del 28&#44;6&#37; para Colombia y un m&#225;ximo del 59&#44;3&#37; para Ecuador&#46; El coste del tratamiento antibi&#243;tico represent&#243; globalmente el 19&#37; del coste total&#59; el resto se debi&#243; a los otros f&#225;rmacos y a la visita m&#233;dica&#46; Las agudizaciones originan un coste importante para los sistemas de salud&#46; Existen importantes variaciones debidas sobre todo a diferencias en los sistemas sanitarios&#46; El tratamiento antibi&#243;tico constituye una peque&#241;a parte del coste global&#46; La utilizaci&#243;n de antibi&#243;ticos m&#225;s eficaces puede ser una estrategia coste-efectiva si logran reducir la tasa de fracasos&#46;"
      ]
    ]
    "multimedia" => array:14 [
      0 => array:8 [
        "identificador" => "tbl1"
        "etiqueta" => "TABLE 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tablaImagen" => array:1 [
                0 => array:4 [
                  "imagenFichero" => "260v39n12-13055460tab01.gif"
                  "imagenAlto" => 334
                  "imagenAncho" => 384
                  "imagenTamanyo" => 12157
                ]
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "Weights Assigned to Each of the Variables Included in the Present Pharmacoeconomic Analysis&#42;"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl2"
        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tablaImagen" => array:1 [
                0 => array:4 [
                  "imagenFichero" => "260v39n12-13055460tab02.gif"
                  "imagenAlto" => 219
                  "imagenAncho" => 381
                  "imagenTamanyo" => 4086
                ]
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "Plan of action for treating exacerbations&#46; 1&#46; Initiating treatment of the exacerbated patient&#46; 2&#46; During the 30 days following initiation no failure is produced&#59; therefore&#44; no presentation at ambulatory or hospital center is observed&#46; 3&#46; A failure is produced&#44; implying that health care resources will be requested&#46; 4&#46; One option is ambulatory service&#46; 5&#46; Another option is hospital emergency room treatment&#46; 6&#46; Ambulatory service resolves the problem without hospitalization&#46; 7&#46; Ambulatory service leads to hospitalization&#46; 8&#46; Emergency room treatment resolves the problem without hospitalization&#46; 9&#46; Emergency room treatment leads to hospitalization&#46;"
        ]
      ]
      2 => array:6 [
        "identificador" => "tbl3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tablaImagen" => array:1 [
                0 => array:4 [
                  "imagenFichero" => "260v39n12-13055460tab03.gif"
                  "imagenAlto" => 42
                  "imagenAncho" => 348
                  "imagenTamanyo" => 2397
                ]
              ]
            ]
          ]
        ]
      ]
      3 => array:6 [
        "identificador" => "tbl4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tablaImagen" => array:1 [
                0 => array:4 [
                  "imagenFichero" => "260v39n12-13055460tab04.gif"
                  "imagenAlto" => 32
                  "imagenAncho" => 345
                  "imagenTamanyo" => 2292
                ]
              ]
            ]
          ]
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl5"
        "etiqueta" => "TABLE 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tablaImagen" => array:1 [
                0 => array:4 [
                  "imagenFichero" => "260v39n12-13055460tab05.gif"
                  "imagenAlto" => 266
                  "imagenAncho" => 387
                  "imagenTamanyo" => 12205
                ]
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "Cost in US Dollars of the Three Types of Medical Care in the Countries Studied&#42;"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl6"
        "etiqueta" => "TABLE 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tablaImagen" => array:1 [
                0 => array:4 [
                  "imagenFichero" => "260v39n12-13055460tab06.gif"
                  "imagenAlto" => 253
                  "imagenAncho" => 378
                  "imagenTamanyo" => 10722
                ]
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "Estimated Direct Health Care Cost in US Dollars for Treatment of Exacerbations and Therapeutic Failure"
        ]
      ]
      6 => array:8 [
        "identificador" => "tbl7"
        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "tablaImagen" => array:1 [
                0 => array:4 [
                  "imagenFichero" => "260v39n12-13055460tab07.gif"
                  "imagenAlto" => 376
                  "imagenAncho" => 380
                  "imagenTamanyo" => 6440
                ]
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "Distribution of the direct health care costs of treating patients with exacerbations&#46;"
        ]
      ]
      7 => array:5 [
        "identificador" => "tbl8"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
      ]
      8 => array:5 [
        "identificador" => "tbl9"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
      ]
      9 => array:5 [
        "identificador" => "tbl10"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
      ]
      10 => array:5 [
        "identificador" => "tbl11"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
      ]
      11 => array:5 [
        "identificador" => "tbl12"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
      ]
      12 => array:5 [
        "identificador" => "tbl13"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
      ]
      13 => array:5 [
        "identificador" => "tbl14"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "copyright" => "Elsevier Espa&#241;a"
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Bibliography"
      "seccion" => array:1 [
        0 => array:1 [
          "bibliografiaReferencia" => array:27 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Estudio epidemiol&#243;gico de la EPOC en Espa&#241;a &#40;IBERPOC&#41;&#58; reclutamiento y trabajo de campo&#46;"
                      "idioma" => "es"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Miravitlles M"
                            1 => "Sobradillo V"
                            2 => "Villasante C"
                            3 => "Gabriel R"
                            4 => "Masa JF"
                            5 => "Jim&#233;nez CA"
                            6 => "et al&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "1999"
                        "volumen" => "35"
                        "paginaInicial" => "152"
                        "paginaFinal" => "8"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10330535"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Geographical variations in prevalence and underdiagnosis of COPD&#46; Results of the IBERPOC multicentre epidemiological study&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Sobradillo V"
                            1 => "Miravitlles M"
                            2 => "Gabriel R"
                            3 => "Jim&#233;nez-Ruiz CA"
                            4 => "Villasante C"
                            5 => "Masa JF"
                            6 => "et al&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2000"
                        "volumen" => "118"
                        "paginaInicial" => "981"
                        "paginaFinal" => "9"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11035667"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Prevalence and risk factors for chronic bronchitis in Pelotas&#44; RS&#44; Brazil&#58; a population-based study&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Menezes AM&#46;B"
                            1 => "Victoria CG"
                            2 => "Rigatto M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "1994"
                        "volumen" => "49"
                        "paginaInicial" => "1217"
                        "paginaFinal" => "21"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7878555"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Recomendaciones ALAT sobre exacerbaci&#243;n infecciosa de la EPOC&#46;"
                      "idioma" => "es"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Grupo de Trabajo de la Asociaci&#243;n Latinoamericana del T&#243;rax &#40;ALAT&#41;&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2001"
                        "volumen" => "37"
                        "paginaInicial" => "349"
                        "paginaFinal" => "57"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11562321"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Epidemiology of chronic obstructive pulmonary disease exacerbations&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Miravitlles M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Pulm Med"
                        "fecha" => "2002"
                        "volumen" => "9"
                        "paginaInicial" => "191"
                        "paginaFinal" => "7"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Pharmacoeconomics of antibacterial treatment&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Davey PG"
                            1 => "Malek MM"
                            2 => "Parker SE&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "PharmacoEconomics"
                        "fecha" => "1992"
                        "volumen" => "1"
                        "paginaInicial" => "409"
                        "paginaFinal" => "37"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10147022"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Treatment of chronic obstructive pulmonary disease and its exacerbations in general practice&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Miravitlles M"
                            1 => "Mayordomo C"
                            2 => "Art&#233;s T"
                            3 => "S&#225;nchez-Agudo L"
                            4 => "Nicolau F"
                            5 => "Seg&#250; JL"
                            6 => "and the EOLO Group&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Med"
                        "fecha" => "1999"
                        "volumen" => "93"
                        "paginaInicial" => "173"
                        "paginaFinal" => "9"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10464874"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "El coste de la enfermedad pulmonar obstructiva cr&#243;nica en Espa&#241;a&#46; Opciones para una optimizaci&#243;n de recursos&#46;"
                      "idioma" => "es"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Miravitlles M"
                            1 => "Figueras M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2001"
                        "volumen" => "37"
                        "paginaInicial" => "388"
                        "paginaFinal" => "93"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11674939"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Pharmacoeconomic evaluation of acute exacerbations of chronic bronchitis and COPD&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Miravitlles M"
                            1 => "Murio C"
                            2 => "Guerrero T"
                            3 => "Gisbert R"
                            4 => "on behalf of the DAFNE Study Group&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2002"
                        "volumen" => "121"
                        "paginaInicial" => "1449"
                        "paginaFinal" => "55"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12006427"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Factors associated with relapse after ambulatory treatment of acute exacerbations of chronic bronchitis&#46; A prospective multicenter study in the community&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Miravitlles M"
                            1 => "Murio C"
                            2 => "Guerrero T"
                            3 => "on behalf of the DAFNE Study Group&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2001"
                        "volumen" => "17"
                        "paginaInicial" => "928"
                        "paginaFinal" => "33"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11488328"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Home hospitalisation of exacerbated chronic obstructive pulmonary disease patients&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Hern&#225;ndez C"
                            1 => "Casas A"
                            2 => "Escarrabill J"
                            3 => "Alonso J"
                            4 => "Puig-Junoy J"
                            5 => "Farrero E"
                            6 => "et al&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2003"
                        "volumen" => "21"
                        "paginaInicial" => "58"
                        "paginaFinal" => "67"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12570110"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib12"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Audit of acute admissions of COPD&#58; standards of care and management in the hospital setting&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Roberts CM"
                            1 => "Ryland I"
                            2 => "Lowe D"
                            3 => "Kelly Y"
                            4 => "Bucknall CE"
                            5 => "Pearson MG&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2001"
                        "volumen" => "17"
                        "paginaInicial" => "343"
                        "paginaFinal" => "9"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11405509"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib13"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Prospective study of aetiology and outcome of adult lower respiratory tract infections in the community&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "MacFarlane JT"
                            1 => "Colville A"
                            2 => "Guion A"
                            3 => "MacFarlane RM"
                            4 => "Rose DH&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "1993"
                        "volumen" => "341"
                        "paginaInicial" => "511"
                        "paginaFinal" => "4"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8094769"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib14"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "El fracaso en el tratamiento de las agudizaciones de la enfermedad pulmonar obstructiva cr&#243;nica&#46; Factores de riesgo e importancia cl&#237;nica&#46;"
                      "idioma" => "es"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Miravitlles M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Clin (Barc)"
                        "fecha" => "2002"
                        "volumen" => "119"
                        "paginaInicial" => "304"
                        "paginaFinal" => "14"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Risk factors for hospitalization for a chronic obstructive pulmonary disease exacerbation&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Garc&#237;a-Aymerich J"
                            1 => "Mons&#243; E"
                            2 => "Marrades RM"
                            3 => "Escarrabill J"
                            4 => "F&#233;lez MA"
                            5 => "Sunyer J"
                            6 => "et al&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.164.6.2006012"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2001"
                        "volumen" => "164"
                        "paginaInicial" => "1002"
                        "paginaFinal" => "7"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11587986"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib16"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Factors associated with increased risk of exacerbation and hospital admission in a cohort of ambulatory COPD patients&#58; a multiple logistic regression analysis&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Miravitlles M"
                            1 => "Guerrero T"
                            2 => "Mayordomo C"
                            3 => "S&#225;nchez-Agudo L"
                            4 => "Nicolau F"
                            5 => "Seg&#250; JL"
                            6 => "on behalf of the EOLO Group&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "67462"
                      "Revista" => array:6 [
                        "tituloSerie" => "Respiration"
                        "fecha" => "2000"
                        "volumen" => "67"
                        "paginaInicial" => "495"
                        "paginaFinal" => "501"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11070451"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "A 1-year community-based health economic study of ciprofloxacin vs usual antibiotic treatment in acute exacerbations of chronic bronchitis&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Grossman R"
                            1 => "Mukherjee J"
                            2 => "Vaughan D"
                            3 => "Eastwood C"
                            4 => "Cook R"
                            5 => "La-Forge J"
                            6 => "et al&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1998"
                        "volumen" => "113"
                        "paginaInicial" => "131"
                        "paginaFinal" => "41"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9440580"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib18"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Relationship between bacterial flora in sputum and functional impairment in patients with acute exacerbations of COPD&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Miravitlles M"
                            1 => "Espinosa C"
                            2 => "Fern&#225;ndez-Laso E"
                            3 => "Martos JA"
                            4 => "Maldonado JA"
                            5 => "Gallego M"
                            6 => "and Study Group of Bacterial Infection in COPD&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1999"
                        "volumen" => "116"
                        "paginaInicial" => "40"
                        "paginaFinal" => "6"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10424501"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib19"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Five day moxifloxacin therapy compared with 7 day clarithromycin therapy for the treatment of acute exacerbations of chronic bronchitis&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Wilson R"
                            1 => "Kubin R"
                            2 => "Ballin I"
                            3 => "Deppermann KM"
                            4 => "Bassaris HP"
                            5 => "Leophonte P"
                            6 => "et al&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Antimicrob Chemother"
                        "fecha" => "1999"
                        "volumen" => "44"
                        "paginaInicial" => "501"
                        "paginaFinal" => "13"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10588312"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib20"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "The safety and efficacy of short course &#40;5-day&#41; moxifloxacin vs&#46; azithromycin in the treatment of patients with acute exacerbation of chronic bronchitis&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "DeAbate CA"
                            1 => "Mathew CP"
                            2 => "Warner JH"
                            3 => "Heyd A"
                            4 => "Church D&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1053/rmed.2000.0927"
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Med"
                        "fecha" => "2000"
                        "volumen" => "94"
                        "paginaInicial" => "1029"
                        "paginaFinal" => "37"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11127487"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib21"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "The efficacy of moxifloxacin in acute exacerbations of chronic bronchitis&#59; a Spanish physician and patient experience&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Miravitlles M"
                            1 => "Ros F"
                            2 => "Cobos A"
                            3 => "Kubin R"
                            4 => "Tillotson G&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Clin Pract"
                        "fecha" => "2001"
                        "volumen" => "55"
                        "paginaInicial" => "437"
                        "paginaFinal" => "41"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11594251"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib22"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "In vitro activity of BAY 12-8039&#44; a new fluoroquinolone&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Woodcock JM"
                            1 => "Andrews JM"
                            2 => "Boswell FJ"
                            3 => "Brenwald NP"
                            4 => "Wise R&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Antimicrob Agents Chemother"
                        "fecha" => "1997"
                        "volumen" => "41"
                        "paginaInicial" => "101"
                        "paginaFinal" => "6"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8980763"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib23"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Designing future clinical trials for acute exacerbations of chronic bronchitis&#46; In&#58; Allegra L&#44; Blasi F&#44; editors&#46; Mechanisms and management of COPD exacerbations&#46; Milan&#58; Springer-Verlag"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Miravitlles M&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:4 [
                        "titulo" => "Designing future clinical trials for acute exacerbations of chronic bronchitis&#46; In&#58; Allegra L&#44; Blasi F&#44; editors&#46; Mechanisms and management of COPD exacerbations&#46; Milan&#58; Springer-Verlag"
                        "fecha" => "2000"
                        "paginaInicial" => "88"
                        "paginaFinal" => "99"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib24"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "A randomized controlled trial of sequential intravenous &#40;i&#46;v&#46;&#41; and oral moxifloxacin compared with sequential i&#46;v&#46; and oral co-amoxiclav with or without clarithromycin in patients with community-acquired pneumonia requiring initial parenteral treatment&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Finch R"
                            1 => "Sch&#252;rmann D"
                            2 => "Collins O"
                            3 => "Kubin R"
                            4 => "McGivern J"
                            5 => "Bobbaers H"
                            6 => "et al&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Antimicrob Agents Chemother"
                        "fecha" => "2002"
                        "volumen" => "46"
                        "paginaInicial" => "1746"
                        "paginaFinal" => "54"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12019085"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib25"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Speed of recovery from acute exacerbations of COPD after treatment with moxifloxacin&#58; results of a two-year study&#46;"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:8 [
                            0 => "Miravitlles M"
                            1 => "Zalacain R"
                            2 => "Murio C"
                            3 => "&#193;lvarez-Sala JL"
                            4 => "Masa JF"
                            5 => "Verea H"
                            6 => "et al"
                            7 => "on behalf of the IMPAC Study Group&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Drug Invest"
                        "fecha" => "2003"
                        "volumen" => "23"
                        "paginaInicial" => "439"
                        "paginaFinal" => "50"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib26"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Farmacoeconom&#237;a&#58; el c&#225;lculo de la eficiencia&#46;"
                      "idioma" => "es"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Sacrist&#225;n JA"
                            1 => "Soto J"
                            2 => "Reviriego J"
                            3 => "Galende I&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Clin (Barc)"
                        "fecha" => "1994"
                        "volumen" => "103"
                        "paginaInicial" => "143"
                        "paginaFinal" => "9"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib27"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "referenciaCompleta" => "Costs of chronic bronchitis and COPD. A one year follow-up study. Chest 2003;123:784-91. Arch Bronconeumol 2003;39(12):549-53 553"
                  "contribucion" => array:1 [
                    0 => array:3 [
                      "titulo" => "Costs of chronic bronchitis and COPD&#46; A one year follow-up study&#46; Chest 2003&#59;123&#58;784-91&#46; Arch Bronconeumol 2003&#59;39&#40;12&#41;&#58;549-53 553"
                      "idioma" => "en"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Miravitlles M"
                            1 => "Murio C"
                            2 => "Guerrero T"
                            3 => "Gisbert R"
                            4 => "on behalf of the DAFNE Study Group&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/15792129/0000003900000012/v0_201307090853/13055460/v0_201307090853/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "14570"
    "tipo" => "SECCION"
    "es" => array:2 [
      "titulo" => "Original papers"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "es"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/15792129/0000003900000012/v0_201307090853/13055460/v0_201307090853/en/260v39n12a13055460pdf001.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/13055460?idApp=UINPBA00003Z"
]

Article information

ISSN: 15792129
Original language: English

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	8	2	10
2024 October	33	15	48
2024 September	52	20	72
2024 August	65	37	102
2024 July	44	23	67
2024 June	45	27	72
2024 May	66	23	89
2024 April	32	29	61
2024 March	21	27	48
2024 February	27	38	65
2023 March	8	3	11
2023 February	35	23	58
2023 January	33	42	75
2022 December	50	41	91
2022 November	54	39	93
2022 October	36	42	78
2022 September	38	28	66
2022 August	39	74	113
2022 July	34	77	111
2022 June	37	43	80
2022 May	39	43	82
2022 April	54	43	97
2022 March	60	54	114
2022 February	51	34	85
2022 January	68	52	120
2021 December	53	44	97
2021 November	65	47	112
2021 October	116	80	196
2021 September	76	50	126
2021 August	70	48	118
2021 July	53	33	86
2021 June	209	54	263
2021 May	95	54	149
2021 April	198	126	324
2021 March	96	24	120
2021 February	83	42	125
2021 January	72	23	95
2020 December	73	48	121
2020 November	59	24	83
2020 October	80	24	104
2020 September	70	27	97
2020 August	46	22	68
2020 July	45	29	74
2020 June	45	13	58
2020 May	56	18	74
2020 April	71	25	96
2020 March	32	25	57
2020 February	46	20	66
2020 January	48	32	80
2019 December	56	62	118
2019 November	49	114	163
2019 October	44	87	131
2019 September	56	104	160
2019 August	36	111	147
2019 July	29	106	135
2019 June	58	92	150
2019 May	90	112	202
2019 April	105	81	186
2019 March	55	22	77
2019 February	44	25	69
2019 January	34	23	57
2018 December	58	24	82
2018 November	77	20	97
2018 October	83	23	106
2018 September	36	17	53
2018 May	22	0	22
2018 April	31	9	40
2018 March	25	4	29
2018 February	34	8	42
2018 January	33	10	43
2017 December	29	4	33
2017 November	45	13	58
2017 October	41	18	59
2017 September	54	9	63
2017 August	84	30	114
2017 July	74	7	81
2017 June	96	11	107
2017 May	90	17	107
2017 April	74	21	95
2017 March	57	14	71
2017 February	37	6	43
2017 January	20	8	28
2016 December	40	10	50
2016 November	66	15	81
2016 October	82	19	101
2016 September	100	17	117
2016 August	83	14	97
2016 July	31	13	44
2016 May	0	12	12
2016 April	0	2	2
2016 March	2	0	2
2016 February	1	11	12
2016 January	0	13	13
2015 December	3	21	24
2015 November	3	9	12
2015 October	51	1	52
2015 September	44	12	56
2015 August	49	11	60
2015 July	40	10	50
2015 June	36	13	49
2015 May	64	20	84
2015 April	35	21	56
2015 March	54	16	70
2015 February	33	8	41
2015 January	35	6	41
2014 December	39	12	51
2014 November	53	16	69
2014 October	54	16	70
2014 September	54	17	71
2014 August	46	14	60
2014 July	35	16	51
2014 June	52	12	64
2014 May	64	14	78
2014 April	63	9	72
2014 March	59	14	73
2014 February	64	12	76
2014 January	47	8	55
2013 December	42	10	52
2013 November	48	7	55
2013 October	50	13	63
2013 September	50	15	65
2013 August	53	20	73
2013 July	51	14	65
2013 June	42	10	52
2013 May	56	9	65
2013 April	35	12	47
2013 March	16	4	20

Show all

Indexed in:

Follow us:

Subscribe:

Statistics

Indexed in:

Follow us:

Subscribe:

Statistics

Subscribe to our newsletter