Original Article
COPD Screening in Primary Care in Four Latin American Countries: Methodology of the PUMA Study
Detección de casos de EPOC en atención primaria en 4 países de Latinoamérica: metodología del Estudio PUMA
Eduardo Schiavia,
, Roberto Stirbulovb, Ramón Hernández Vecinoc, Sandra Mercuriod, Valentina Di Bosciod, on behalf of the Puma Team e
Corresponding author
a Hospital de Rehabilitación Respiratoria “María Ferrer”, Buenos Aires, Argentina
b Departamento de Neumología, Facultad de Ciencias Médicas de Santa Casa de São Paulo, Sao Paulo, Brazil
c Departamento Médico, AstraZeneca LatAm, Miami, United States
d Departamento Médico, AstraZeneca S.A., Buenos Aires, Argentina
e Details of the members of the PUMA team, the list of Steering Committee members and names of the National Study Coordinators can be found in the Acknowledgements section
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=> array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2496 "Ancho" => 2503 "Tamanyo" => 301059 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow chart. Patient screening.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic obstructive pulmonary disease (COPD) is a common, preventable, and treatable condition characterized by progressive, partially reversible airway obstruction that can be associated with dyspnea, cough, and sputum production.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> The worldwide impact of COPD is increasing, and it is becoming one of the major causes of mortality, morbidity, and loss of quality of life, contributing to rising social and medical costs.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Early diagnosis and appropriate treatment are essential to prevent COPD and minimize the progress and consequences of this disease.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Since COPD can be asymptomatic in the early stages and diagnosis requires spirometric evaluation for confirming airway obstruction, underdiagnosis, and misdiagnosis are very common, particularly at disease onset.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3,6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Numerous COPD population-based studies (PLATINO, BOLD, EPISCAN) have been conducted in different countries, reporting a prevalence of around 10%–15% in the study population.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–9</span></a> In the PLATINO study (Chronic Obstructive Pulmonary Disease in Five Latin American Cities), the prevalence among the populations of 5 Latin American cities was, on average, 14.3%.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In this study, 89% of individuals found to have COPD according to the spirometry results did not have a previous diagnosis, while 64% of subjects who claimed to have COPD showed no airway limitation on spirometry, and only 20% had ever performed spirometry testing at any time in their lives. This suggests that the diagnosis of COPD is severely limited by the underuse of spirometry.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Less information is available on the prevalence of COPD in the population attending primary care centers. The limited data available in the international literature suggest a significantly higher figure of around 20% in this population.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">11,12</span></a> The only Latin American study conducted in this context reported a prevalence of 20.6% in 27 Mexican cities.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">13</span></a> Early-stage or undiagnosed patients are more likely to be found at the primary care level, therefore the prevalence of the disease at this stage must be determined in order to plan and implement appropriate early detection and management strategies.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">11,12</span></a> Data from prevalence studies are complemented by data from the primary care population. Both are necessary for defining a comprehensive healthcare approach.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Given the prevailing situation, the PUMA study was proposed [Prevalence Study and Regular Practice (Diagnosis and Treatment) Among General Practitioners in Populations at Risk of COPD in Latin America–clinicaltrials.gov identifier: <a id="intr0010" class="elsevierStyleInterRef" href="https://clinicaltrials.gov/NCT01493544">NCT01493544</a>]. This study was designed to estimate the prevalence, determining factors for underdiagnosis and misdiagnosis and treatment of COPD among high-risk patients attending primary care centers for whatever reason in Argentina, Colombia, Uruguay, and Venezuela. The methodology is described below.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design and Study Population</span><p id="par0030" class="elsevierStylePara elsevierViewall">The PUMA study is a multicenter, multinational, cross-sectional, non-interventionist study. A steering committee composed of experts in epidemiology and respiratory medicine in Latin America was appointed to design the protocol and standardize the methodology. An expert pulmonologist was also appointed as national coordinator for each country.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Study sites in each country were selected to reflect the reality of national primary care practice in terms of geographical distribution (urban or rural) and healthcare sector (public or private). Participating sites included primary care centers (family doctors, general practitioners, etc.) with no direct connection with respiratory medicine specialists. The study was approved by the ethics committees for each site and all participants gave their informed consent.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The study population consisted of patients with a high risk of COPD attending participating primary care centers in Argentina, Colombia, Uruguay, and Venezuela. They were enrolled during routine spontaneous or scheduled visits and their medical appointment was unrelated to the study. To be considered high risk, patients had to meet the following inclusion criteria: ≥40 years, current or former smokers (≥10 pack-years, ≥50 pipes/year, or ≥50 cigars/year), and/or exposure to biomass smoke, such as wood or coal, for cooking or heating (exposure ≥100<span class="elsevierStyleHsp" style=""></span>h/year).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Exclusion criteria were pregnancy, contraindication for spirometry (chest, abdominal or brain surgery; acute coronary syndrome; retinal detachment; hospitalization for any heart complaint during the previous 3 months), heart rate ≥120<span class="elsevierStyleHsp" style=""></span>bpm, physical or mental disability rendering the patient unable to complete the study procedures, currently undergoing treatment for tuberculosis or concurrent participation in a clinical trial.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Each center was assigned a number of patients for enrollment. The recruitment period in each center depended on the number of patients with inclusion criteria presenting in the center and completing the study.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Patients were consecutively selected for participation in the study according to the order in which they were seen. Those who did not meet the inclusion criteria continued with their scheduled appointment.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Personnel Qualifications</span><p id="par0065" class="elsevierStylePara elsevierViewall">The national coordinators were responsible for the training and certification of staff involved in completing questionnaires and performing spirometries. This was carried out in each country by way of a training session and use of a standardized evaluation designed specifically for this study, based on the recommendations of the American Thoracic Society (ATS).<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">14</span></a> Investigator meetings were held to ensure compliance with the procedures and quality standards. The national coordinators standardized the spirometry procedure and reported and monitored the quality of the maneuvers performed. Personnel in the field sent the spirometries in digital format to the national coordinator within 24<span class="elsevierStyleHsp" style=""></span>h after performance. Approval of the technical quality was required before recruitment in a center could be completed. Only spirometries approved by the coordinator were considered validated. If the spirometry was not validated, it was either repeated as soon as possible or the spirometry for that patient was excluded.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study Procedures</span><p id="par0070" class="elsevierStylePara elsevierViewall">Investigators were responsible for selecting the study population according to the inclusion and exclusion criteria and for obtaining informed consent. Data were obtained from the physicians and from the patients on standardized questionnaires (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">The age and sex, years of experience in general medicine, professional training, smoking history, average number of patients seen per day, teaching activities, location of the study center (urban/rural), medical practice characteristics (public/private), factors limiting use of COPD guidelines and available diagnostic and therapeutic resources of each physician were recorded in the <span class="elsevierStyleItalic">Investigator's Questionnaire</span>.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Physicians recorded data from clinical records, including spirometries, diagnoses, previous treatments, and concomitant diseases in the <span class="elsevierStyleItalic">Background Questionnaire.</span></p><p id="par0085" class="elsevierStylePara elsevierViewall">The physician checked if the patient could perform spirometry and oximetry during their visit. Patients were then referred to personnel qualified to perform the test and complete the corresponding questionnaire. To complete the <span class="elsevierStyleItalic">PUMA Questionnaire</span> (modified version of the PLATINO study questionnaire), the patient was directly interviewed by trained personnel. Patients who not only met the inclusion criteria but also met any of the exclusion criteria were invited to participate in the <span class="elsevierStyleItalic">Minimum Data Questionnaire</span> (basic demographic data and smoking habit).</p><p id="par0090" class="elsevierStylePara elsevierViewall">The primary outcome variable was diagnosis of COPD based on spirometry. Subjects with COPD were defined as those with an FEV<span class="elsevierStyleInf">1</span>/FVC (forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s divided by forced vital capacity) ratio of less than 0.7. COPD prevalence was also estimated on the basis of other spirometric criteria such as the GOLD classification (<a id="intr0015" class="elsevierStyleInterRef" href="http://www.goldcopd.org/">http://www.goldcopd.org</a>) and lower limit of normal (LLN) criteria. Independent variables were obtained from the questionnaires and included demographic data, smoking habit, environmental/domestic pollution, symptoms/history, and treatment of respiratory diseases, concomitant diseases and use of healthcare resources.</p><p id="par0095" class="elsevierStylePara elsevierViewall">If the patient presented any transient criterion that would prevent performance of the spirometry, the questionnaire was completed and a second visit was scheduled. Criteria for postponing spirometry included the use of short-acting bronchodilators in the previous 3<span class="elsevierStyleHsp" style=""></span>h, long-acting beta-adrenergic bronchodilators in the previous 12<span class="elsevierStyleHsp" style=""></span>h, long-acting anticholinergics in the previous 24<span class="elsevierStyleHsp" style=""></span>h, smoking cigarettes, pipes or other tobacco products in the previous 2<span class="elsevierStyleHsp" style=""></span>h, physical exercise, including working out, walking or jogging in the previous hour, and concurrent acute respiratory infection at the time of the visit.</p><p id="par0100" class="elsevierStylePara elsevierViewall">Height and weight data were measured using calibrated equipment. Spirometries were obtained in all centers using an ultrasound spirometer (Easy One by NDD TECHNOPARK, Medical Technologies, Inc. Two Dundee Park, Andover, MA, U.S.A.) that met ATS quality control requirements.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">14</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">To determine spirometric acceptability and reproducibility, ATS criteria (150–200<span class="elsevierStyleHsp" style=""></span>ml in a minimum of 8 and maximum of 15 maneuvers) were used to obtain reproducible measurements. Spirometries were carried out with the patients in a sitting position using nasal clips. Each participant completed 2 spirometric tests– baseline spirometry examination and a second test 15<span class="elsevierStyleHsp" style=""></span>min after the administration of 400<span class="elsevierStyleHsp" style=""></span>μg of aerosol salbutamol administered with a spacer.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Oximetry was carried out using a digital pulse oximeter after the patient had been resting for 5<span class="elsevierStyleHsp" style=""></span>min and before receiving the bronchodilator for the spirometry (Riestet-ri-fox N pulse Oximeter [Rudolf Riester GmbH – Bruckstrasse 31, D-72417 Jungingen, Germany] or NONIN Onyx 9500 Oximeter [Nonin Medical, Inc., 13700 1st Avenue, North Plymouth, MN, USA]). The evaluation was performed with the patient in a sitting position breathing room air with the oximeter attached to the right index finger. The average of 6 measurements obtained at 10-s intervals was recorded. In addition, the heart rate provided by the device was recorded. The flow chart for patient selection is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>, and the procedures performed during the visit are described in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical Analysis</span><p id="par0115" class="elsevierStylePara elsevierViewall">The original size of the sample calculated for studying the prevalence of COPD confirmed by spirometry in the study population of each country (estimated at 20%) with a 3% margin of error was a minimum of 715 subjects per country. The planned sample size was reached only in Venezuela, where 721 patients had completed the PUMA questionnaire by the end of enrollment. Thus, in Argentina and Colombia, with 454 and 465 subjects enrolled, respectively, the margin of error for the estimated prevalence is 3.7%. To increase the sample size for the pooled analysis, 103 patients were included from Uruguay.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In addition to country-specific analyses, some risk factor tests will be performed on the overall study population. In such cases, statistical power is at least 90%, with probability indexes of (a) 1.4 or greater for exposure factors affecting 20% of the disease-free population and (b) 1.6 or greater for exposure factors affecting 10% of the disease-free population. For secondary endpoints restricted to participants with COPD (planned n=572), margins of error for proportions of 10%, 20%, and 50% are 2.5%, 3.5%, and 4.2% respectively.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Descriptive statistics include calculations of means, medians, standard deviations and ranges for continuous variables and proportions and their respective 95% confidence intervals for categorical variables. The prevalence and treatment of COPD will be studied for each country with the exception of Uruguay, due to the small sample size. Most of the remaining analyses will be performed on the pooled sample, except when heterogeneity testing suggests the need for country-specific analyses. In bivariate analyses, proportions will be compared using the Chi-squared test for heterogeneity and linear trend. Differences in means will be investigated with the <span class="elsevierStyleItalic">T</span>-test or one-way ANOVA. For multivariate analyses, logistic and linear regressions will be used for categorical and continuous results, respectively. Statistical analysis will be performed using Stata, version 12 (<a id="intr0020" class="elsevierStyleInterRef" href="http://www.stata.com/">www.stata.com</a>).</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><p id="par0130" class="elsevierStylePara elsevierViewall">The protocol was finalized in August 2011. During the 3rd quarter of 2011 and the 1st quarter of 2012, each participating country obtained approval to conduct the study from their corresponding ethics committees and/or national authorities, depending on local regulations for this type of study. The time required for this process varied in each country, and these differences affected the recruitment period.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The first patient was enrolled in Argentina on February 6, 2012 and the last was completed in Colombia on October 31, 2012 (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). The database closed on November 30, 2012.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The number of centers in each participating country varied, reflecting local primary care practices. A total of 57 centers took part.</p><p id="par0145" class="elsevierStylePara elsevierViewall">In total, 1907 patients were enrolled, of which 1790 were eligible, meeting all of the inclusion criteria and none of the exclusion criteria. One hundred (100) patients were excluded due to violation of inclusion criteria, and 17 met at least one of the exclusion criteria. This latter group completed the <span class="elsevierStyleItalic">Minimum Data Questionnaire.</span></p><p id="par0150" class="elsevierStylePara elsevierViewall">Of the 1790 eligible patients, 47 refused to complete the <span class="elsevierStyleItalic">PUMA Questionnaire</span>, but did complete the <span class="elsevierStyleItalic">Minimum Data Questionnaire</span>, therefore, a total of 1743 patients completed the <span class="elsevierStyleItalic">PUMA Questionnaire</span>. Of these, 1540 had acceptable spirometries according to the criteria of the national coordinators. Thus, 88.4% of the patients who completed the <span class="elsevierStyleItalic">PUMA Questionnaire</span> had valid spirometries; the prevalence of COPD was assessed in this population (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Discussion</span><p id="par0155" class="elsevierStylePara elsevierViewall">The PUMA study is an observational, multicenter, multinational, cross-sectional study in a patient population at high risk for COPD attending routine or spontaneous visits in a primary care center. Since the study was specifically designed to evaluate the prevalence of spirometry-confirmed COPD in this patient population, it can be termed an opportunistic case screening study.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Different values from those reported in general population studies have been revealed in case-finding studies in primary care, underlining the need for obtaining specific results in this patient group for proper healthcare planning. Laniado-Laborin et al. used case-finding methods among primary care physicians in 27 cities in Mexico.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">13</span></a> They found a 20.6% prevalence of COPD, significantly greater than the rates reported in the PLATINO study for Mexico City (7.8%), in the EPI-SCAN study for Spain (10.2%) and in a review of epidemiological studies (4%–10%), all of which were population-based.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,9,15</span></a> In a 3-center primary care study, Hill et al. also found a 20.7% prevalence, of which only 32% were previously aware of their diagnosis.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">11</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">One strength of this study is the use of a strict protocol in a predefined population applying a similar study methodology in all centers based on validated questionnaires and standardized spirometry with similar equipment that, moreover, allowed the results to be compared using different spirometric criteria (GOLD, LLN).<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The Lanaido-Laborin study did not evaluate a randomized patient sample but rather patients pre-selected by general practitioners, and is therefore prone to bias.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">13</span></a> To avoid such issues in the PUMA study, centers were selected on the basis of available lists of primary care physicians and the study patients were those who visited the center spontaneously. Despite the efforts made to ensure a representative sample, we are aware that there may be some problems regarding the precision of external validity. Nevertheless, the procedure used was the most reasonable in view of the operational possibilities in each country.</p><p id="par0175" class="elsevierStylePara elsevierViewall">The PUMA study will clarify the prevalence of underdiagnosis and misdiagnosis of COPD associated with the underuse of spirometry in the population of 4 Latin American countries. The multicenter, multinational nature of the study is another important aspect, since this will give a comparative overview of several countries studied using the same methodology. The above-mentioned potential external validity issues will need to be addressed in the analysis of results and inter-country variations.</p><p id="par0180" class="elsevierStylePara elsevierViewall">A large amount of additional data has been collected via the <span class="elsevierStyleItalic">PUMA Questionnaire</span> that will be useful for evaluating key issues such as demographic influence and socioeconomic factors, the presence of symptoms, exacerbations and the treatment of respiratory conditions and concomitant diseases impacting on both symptom severity and patient quality of life and the risk of hospitalization and death.<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">15–17</span></a> The heterogeneity of all these factors among the participating countries will be analyzed.</p><p id="par0185" class="elsevierStylePara elsevierViewall">This study may also help to elucidate the role of primary care physicians in the appropriate use of healthcare and therapeutic resources, and will assist in the development of strategies for guiding these physicians toward improving the diagnosis and management of COPD.</p><p id="par0190" class="elsevierStylePara elsevierViewall">In the PUMA study, almost 90% of patients who completed the <span class="elsevierStyleItalic">PUMA Questionnaire</span> had valid spirometries performed in primary care. This suggests that it may be possible to use case-finding techniques to achieve earlier diagnosis. There is little doubt that early diagnosis modifies the natural course of a disease that is frequently underdiagnosed and generally remains unidentified until the advanced stages.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Number of words of main part of the manuscript: 2594.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0200" class="elsevierStylePara elsevierViewall">This observational study was sponsored by <span class="elsevierStyleGrantSponsor" id="gs1">AstraZeneca América Latina</span>.</p><p id="par0205" class="elsevierStylePara elsevierViewall">Editorial support was provided by Flow Healthcare Consultancy, funded by AstraZeneca.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of Interests</span><p id="par0210" class="elsevierStylePara elsevierViewall">Eduardo Schiavi has received fees for speaking engagements and/or scientific consultancy from AstraZeneca, Boehringer Ingelheim, and Takeda.</p><p id="par0215" class="elsevierStylePara elsevierViewall">Roberto Stirbulov has received fees for speaking engagements and/or scientific consultancy from Boehringer Ingelheim and Novartis.</p><p id="par0220" class="elsevierStylePara elsevierViewall">Ramón Hernández was an employee of AstraZeneca Latinoamérica during the design and development of the PUMA study.</p><p id="par0225" class="elsevierStylePara elsevierViewall">Sandra Mercurio is an employee of AstraZeneca Argentina.</p><p id="par0230" class="elsevierStylePara elsevierViewall">Valentina Di Boscio is an employee of AstraZeneca Argentina.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Author Contribution</span><p id="par0235" class="elsevierStylePara elsevierViewall">ES contributed to the concept and design of this study and participated in the writing and critical review of this manuscript. RS contributed to the concept and design of this study. SM contributed to the concept and design of this study and participated in the writing and critical review of this manuscript. VDB contributed to the concept and design of this study and participated in the writing and critical review of this manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:2 [ "identificador" => "xres379773" "titulo" => array:5 [ 0 => "Abstract" 1 => "Introduction" 2 => "Methods" 3 => "Results" 4 => "Conclusions" ] ] 1 => array:2 [ "identificador" => "xpalclavsec358586" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres379774" "titulo" => array:5 [ 0 => "Resumen" 1 => "Introducción" 2 => "Métodos" 3 => "Resultados" 4 => "Conclusiones" ] ] 3 => array:2 [ "identificador" => "xpalclavsec358585" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Design and Study Population" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Personnel Qualifications" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Study Procedures" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical Analysis" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of Interests" ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Author Contribution" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-10-03" "fechaAceptado" => "2014-03-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec358586" "palabras" => array:6 [ 0 => "Chronic obstructive pulmonary disease" 1 => "Prevalence" 2 => "Diagnosis" 3 => "Spirometry" 4 => "Primary care" 5 => "Opportunistic screening" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec358585" "palabras" => array:6 [ 0 => "Enfermedad pulmonar obstructiva crónica" 1 => "Prevalencia" 2 => "Diagnóstico" 3 => "Espirometría" 4 => "Atención primaria" 5 => "Detección de casos oportunista" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">The prevalence of COPD among patients treated in the healthcare system in Latin America is unknown. The PUMA study (Prevalencia y práctica habitUal –diagnóstico y tratamiento– en población de riesgo de EPOC en Médicos generalistas de 4 países de América Latina) screened at-risk patients attending primary care centers to evaluate the prevalence, diagnosis, and treatment of COPD in this setting. The aim of this report is to describe the study methodology.</p> <span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Multicenter, observational, cross-sectional study conducted in Argentina, Colombia, Uruguay, and Venezuela. Subjects were ≥40 years, smokers, former smokers, and/or exposed to fossil fuels attending primary care centers. Eligible patients underwent pre- and post-bronchodilator spirometry and completed standardized questionnaires on demographics, smoking, exposure to environmental/domestic pollution, symptoms/history, and management of respiratory diseases, comorbidities, and use of healthcare resources.</p> <span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A total of 57 centers in 4 countries participated; 1907 patients were included, 1743 completed the PUMA questionnaire and 1540 patients underwent validated spirometry.</p> <span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">We describe the methodology used in the PUMA study, the first systematic multicenter study in four Latin American countries aimed at detecting COPD cases confirmed by spirometry in primary care. Approximately 90% of patients who completed the PUMA questionnaire underwent valid spirometry tests. This gives room for reflection on the feasibility of opportunistic screening at the primary care level to detect patients in the early stages of COPD or with undiagnosed COPD, and improve the diagnosis and management of this disease.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span class="elsevierStyleSectionTitle" id="sect0035">Introducción</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Se desconoce la prevalencia de EPOC entre pacientes que acuden al sistema de salud en Latinoamérica. El estudio Prevalencia y práctica habitUal –diagnóstico y tratamiento– en población de riesgo de EPOC en Médicos generalistas de 4 países de América Latina (PUMA) evalúa prevalencia, diagnóstico y tratamiento de EPOC en pacientes en riesgo que acuden a atención primaria constituyéndose en detección de casos oportunista. El objetivo de esta publicación es describir la metodología del estudio.</p> <span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Estudio multicéntrico, observacional, transversal, realizado en Argentina, Colombia, Uruguay y Venezuela. Participaron pacientes ≥<span class="elsevierStyleHsp" style=""></span>40 años, fumadores o ex fumadores y/o expuestos a combustión de biomasa que acudieron a consultas de atención primaria. Los pacientes elegibles realizaron espirometrías pre y posbroncodilatador y respondieron cuestionarios estandarizados sobre datos demográficos, hábito tabáquico, exposición a polución ambiental/doméstica, síntomas/antecedentes y manejo de enfermedades respiratorias, comorbilidades y uso de recursos sanitarios.</p> <span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Participaron 57 centros en 4 países. Se reclutaron 1.907 pacientes, 1.743 completaron el <span class="elsevierStyleItalic">Cuestionario PUMA</span> y 1.540 pacientes realizaron espirometrías validadas.</p> <span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Describimos la metodología empleada en el estudio PUMA, primer estudio sistemático multicéntrico realizado en 4 países de Latinoamérica para detección de casos de EPOC confirmados por espirometría en atención primaria. Aproximadamente el 90% de los pacientes que realizaron el <span class="elsevierStyleItalic">Cuestionario PUMA</span> realizaron espirometrías válidas. Esto permite reflexionar sobre la factibilidad de realizar detección de casos oportunista en el primer nivel asistencial para encontrar pacientes en estadios tempranos o no diagnosticados y mejorar el diagnóstico y manejo de EPOC en atención primaria.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as: Schiavi E, Stirbulov R, Hernández Vecino R, Mercurio S, Di Boscio V, en nombre del Equipo Puma. Detección de casos de EPOC en atención primaria en 4 países de Latinoamérica: metodología del Estudio PUMA. Arch Bronconeumol. 2014;50:469–474.</p>" ] ] "multimedia" => array:5 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2496 "Ancho" => 2503 "Tamanyo" => 301059 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Flow chart. Patient screening.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2285 "Ancho" => 1758 "Tamanyo" => 221784 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patient screening process.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Study visit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Visit 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Visit 2<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">d</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient informed consent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Inclusion and exclusion criteria \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Investigator Questionnaire</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Minimum Data Questionnaire</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">PUMA Questionnaire</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient history questionnaire<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spirometry \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oximetry \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab578286.png" ] ] ] "notaPie" => array:4 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">This questionnaire was completed once for each investigator.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This questionnaire was administered to any patient who met any exclusion criterion or who did not wish to complete all study procedures.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Applicable only to patients with previous clinical history.</p>" ] 3 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "d" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">The second visit was scheduled only for patients who met any criteria that would prevent or delay spirometry.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Questionnaires and Visit Activities.</p>" ] ] 3 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Argentina n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Colombia n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Uruguay n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Venezuela n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Time between enrollment of first patient and completion of last patient \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 months \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 months (maximum) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Final sample size \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">506 (26.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">476 (25.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">112 (5.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">813 (42.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1907 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab578284.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Patient Numbers by Country.</p>" ] ] 4 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Argentina n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Colombia n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Uruguay n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Venezuela n (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Total n (%) \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Eligible patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">491 (26.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">467 (26.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">104 (5.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">726 (40.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1790 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">All inclusion criteria met but refuses to complete <span class="elsevierStyleItalic">PUMA Questionnaire</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">37 (7.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 (0.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">47 (2.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Minimum Data Questionnaire</span> completed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42 (8.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 (2.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (1.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (1.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64 (3.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Overall <span class="elsevierStyleItalic">PUMA Questionnaire</span> response rate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">454 (91.5) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">465 (97.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">103 (98.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">721 (98.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1743 (96.5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Validated spirometries \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">446 (98.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">326 (70.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">103 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">665 (92.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1540 (88.4) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab578285.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Response Rates by 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| Year/Month | Html | Total | |
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| 2024 November | 5 | 2 | 7 |
| 2024 October | 40 | 25 | 65 |
| 2024 September | 60 | 23 | 83 |
| 2024 August | 76 | 37 | 113 |
| 2024 July | 60 | 32 | 92 |
| 2024 June | 86 | 29 | 115 |
| 2024 May | 91 | 36 | 127 |
| 2024 April | 55 | 36 | 91 |
| 2024 March | 67 | 19 | 86 |
| 2024 February | 45 | 22 | 67 |
| 2023 November | 1 | 0 | 1 |
| 2023 August | 1 | 0 | 1 |
| 2023 March | 11 | 6 | 17 |
| 2023 February | 34 | 33 | 67 |
| 2023 January | 32 | 35 | 67 |
| 2022 December | 52 | 35 | 87 |
| 2022 November | 63 | 29 | 92 |
| 2022 October | 63 | 51 | 114 |
| 2022 September | 46 | 29 | 75 |
| 2022 August | 48 | 50 | 98 |
| 2022 July | 54 | 38 | 92 |
| 2022 June | 50 | 43 | 93 |
| 2022 May | 50 | 56 | 106 |
| 2022 April | 54 | 27 | 81 |
| 2022 March | 86 | 47 | 133 |
| 2022 February | 40 | 43 | 83 |
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| 2021 December | 54 | 52 | 106 |
| 2021 November | 65 | 49 | 114 |
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| 2021 September | 40 | 45 | 85 |
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| 2021 July | 27 | 31 | 58 |
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| 2021 March | 51 | 33 | 84 |
| 2021 February | 40 | 20 | 60 |
| 2021 January | 30 | 16 | 46 |
| 2020 December | 38 | 26 | 64 |
| 2020 November | 38 | 17 | 55 |
| 2020 October | 26 | 16 | 42 |
| 2020 September | 35 | 15 | 50 |
| 2020 August | 38 | 15 | 53 |
| 2020 July | 41 | 20 | 61 |
| 2020 June | 41 | 8 | 49 |
| 2020 May | 38 | 19 | 57 |
| 2020 April | 29 | 25 | 54 |
| 2020 March | 43 | 13 | 56 |
| 2020 February | 44 | 15 | 59 |
| 2020 January | 63 | 25 | 88 |
| 2019 December | 52 | 26 | 78 |
| 2019 November | 45 | 18 | 63 |
| 2019 October | 38 | 22 | 60 |
| 2019 September | 27 | 6 | 33 |
| 2019 August | 36 | 18 | 54 |
| 2019 July | 37 | 28 | 65 |
| 2019 June | 28 | 24 | 52 |
| 2019 May | 48 | 23 | 71 |
| 2019 April | 31 | 24 | 55 |
| 2019 March | 57 | 27 | 84 |
| 2019 February | 43 | 18 | 61 |
| 2019 January | 52 | 22 | 74 |
| 2018 December | 63 | 22 | 85 |
| 2018 November | 105 | 26 | 131 |
| 2018 October | 85 | 23 | 108 |
| 2018 September | 30 | 12 | 42 |
| 2018 May | 15 | 1 | 16 |
| 2018 April | 32 | 6 | 38 |
| 2018 March | 43 | 10 | 53 |
| 2018 February | 38 | 8 | 46 |
| 2018 January | 29 | 7 | 36 |
| 2017 December | 35 | 10 | 45 |
| 2017 November | 28 | 5 | 33 |
| 2017 October | 30 | 8 | 38 |
| 2017 September | 36 | 6 | 42 |
| 2017 August | 49 | 12 | 61 |
| 2017 July | 32 | 6 | 38 |
| 2017 June | 70 | 19 | 89 |
| 2017 May | 73 | 13 | 86 |
| 2017 April | 57 | 3 | 60 |
| 2017 March | 58 | 32 | 90 |
| 2017 February | 38 | 7 | 45 |
| 2017 January | 31 | 6 | 37 |
| 2016 December | 54 | 8 | 62 |
| 2016 November | 75 | 11 | 86 |
| 2016 October | 77 | 18 | 95 |
| 2016 September | 143 | 33 | 176 |
| 2016 August | 66 | 11 | 77 |
| 2016 July | 37 | 13 | 50 |
| 2016 March | 2 | 0 | 2 |
| 2016 February | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 63 | 3 | 66 |
| 2015 September | 70 | 7 | 77 |
| 2015 August | 47 | 12 | 59 |
| 2015 July | 61 | 12 | 73 |
| 2015 June | 44 | 7 | 51 |
| 2015 May | 47 | 11 | 58 |
| 2015 April | 34 | 10 | 44 |
| 2015 March | 32 | 9 | 41 |
| 2015 February | 30 | 12 | 42 |
| 2015 January | 2 | 2 | 4 |
| 2014 November | 0 | 3 | 3 |
Show all
