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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Over the last 60 years&#44; we have witnessed a gradual change in the typical individual seeking healthcare&#46; Our patient populations are now characterized by advancing age&#44; increased incidence of chronic diseases&#44; and a high prevalence of pluripathology&#46; While it is true that chronic diseases can develop at any time during a patient&#39;s lifetime&#44; these 3 features are closely interrelated&#44; so it is equally true that their prevalence increases with advancing age&#46; The same occurs with the development of comorbidities&#46; In the specific case of the lung&#44; aging is associated with genomic instability and epigenetic changes that are key factors in the development of chronic lung diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> According to the World Health Organization &#40;WHO&#41;&#44; chronic diseases account for over 60&#37; of all deaths worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Add to this the impact of these diseases on patient and caregivers&#8217; quality of life&#44; years of life lost&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> the economic burden and the costs of healthcare resources&#44; and it is easy to understand how the care of chronic patients may be a major challenge for healthcare providers&#46; The duty of these bodies is to achieve the best quality of care in chronicity&#44; while continuing to offer the same level of care to acute cases&#46; Improvements in social and healthcare standards mean that Spain is now among the countries with the longest life expectation worldwide&#44; but the outcome of this is an increase in elderly subjects with chronic diseases&#46; Chronic diseases currently account for 80&#37; of consultations in primary care centers and 60&#37; of hospital stays&#44; particularly with respect to unscheduled admissions&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> It is estimated that by 2050&#44; 35&#37; of our population will be older than 75 years&#44; so an exponential increase in the rate of chronic disease is only to be expected&#46; The care of patients with chronic diseases&#44; therefore&#44; will be one of the most important challenges to be faced by the Spanish healthcare system in coming years&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The WHO has called on governments to introduce measures based on 3 key elements&#58; mapping chronic diseases and social&#44; economic&#44; behavioral and political factors&#59; reducing exposure to risk factors&#59; and reinforcing healthcare provisions&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> The implementation of specifically designed models for caring for populations with chronic diseases has been shown to be an efficient approach in various healthcare systems&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">6&#44;7</span></a> These models&#44; the most widely known of which is the Chronic Care Model &#40;CCM&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> advocate a proactive approach&#44; with a patient-centered&#44; participative&#44; multidisciplinary team with well-defined roles&#44; in which shared decision-making is based on scientific evidence and on the preferences of the patient and their family members&#46; An essential aspect of this approach is the availability of efficient information systems&#46; The CCM&#44; in particular&#44; introduced the concepts of integrated care&#44; disease management and case management&#46; Another reference in the management of chronic care patients is the populational model known as &#8220;Kaiser Permanente&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> This system stratifies the population as a pyramid&#44; so that the complexity of care can be adapted to the needs of each stratum or level&#46; Both types of model can be taken as complementary&#44; in line with the WHO&#39;s proposal for the development of an Innovative Care for Chronic Conditions Framework&#44; in which 5 building blocks are specified&#58; populational health approach&#44; awareness and prevention of chronic disease&#44; patient responsibility and autonomy&#44; continuity of care&#44; and interventions tailored to patient needs&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Just 3 years ago&#44; the Ministry of Health&#44; Social Policy and Equality published a document entitled &#8220;A strategic approach to chronicity in the National Healthcare System&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> According to this document&#44; chronicity must be approached from a multidisciplinary perspective&#44; to ensure continuity of care and the full participation of the patient and their family&#47;caregivers&#46; In this model&#44; primary care teams logically play a key role as the hub for coordinating care&#46; Nevertheless&#44; it is surprising that scientific societies and specialists involved in the care of the most common chronic diseases&#44; such as pulmonologists &#40;COPD and chronic respiratory failure&#41;&#44; cardiologists &#40;heart failure&#41;&#44; or endocrinologists &#40;diabetes mellitus&#41; were not involved in the preparation of these recommendations&#46; Before this strategy was published&#44; autonomous communities&#44; such as the Basque Country or Catalonia had already set down guidelines for the care of chronic conditions&#46; Subsequently&#44; strategic plans to develop community-specific programs were published by the remaining autonomous communities of Spain&#46; However&#44; the models are very far from uniform&#44; and while in Madrid the involvement of different specialists is more notable&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> other communities follow the general&#44; national model&#46; Under the pretext of providing a more integrated approach to care in these patients&#44; their aim is to focus on the internist as the central figure in patient management in hospitals&#44; and on the family doctor in outpatient care&#46; The role of the specialist is vague and relegated to the sidelines&#44; a factor that can considerably undermine the quality of care&#46; The significant progress in healthcare achieved by Spain in recent decades&#44; it should be noted&#44; is due to major advances in specialty care and therapeutic and diagnostic techniques&#44; and in this time the &#8220;generalist&#8221; healthcare system has given way to a &#8220;specialized&#8221; system&#46; However&#44; the approach to chronic disease in the new care models amounts to a step backwards rather than forwards&#44; motivated by the pursuit of theoretical savings&#44; doubtless due to an incomplete analysis of the problem&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A patient is usually classified as &#8220;chronic&#8221; when he or she presents chronic disease in a single organ&#46; Even in those cases in which other&#44; more or less important comorbidities are present&#44; the role of the specialist physician caring for the main chronic disease and their collaboration with other specialists&#44; with the family doctor&#44; nursing staff and the social services&#44; is essential&#46; In this model&#44; the chronic patient is confused with the pluripathological patient&#44; which is a serious mistake&#44; since the same criteria are applied in both cases&#44; when the approach should be different&#46; There is no doubt that any chronicity strategy must ensure continuity of care&#44; and instruments and algorithms for coordinating various healthcare levels and the social services must be designed for this purpose&#46; This does not&#44; however&#44; mean ignoring the major role of the specialist who is most aware of all aspects of the disease&#44; and who must&#44; of necessity&#44; direct the care strategy&#46; Primary care and specialist inpatient and outpatient medicine must work hand in hand to achieve continuity of care for the patient&#46; In this context&#44; the nurse case manager and the provision of adequate social support are of particular importance&#46; Integrated care is essential&#44; but without sacrificing scientific and technical quality&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this respect&#44; the highly interesting article published in this issue of <span class="elsevierStyleItalic">Archivos de Bronconeumolog&#237;a</span> by Dr&#46; Soler-Catalu&#241;a et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> could not have come at a better time&#46; The authors have clarified and evaluated what might be the role of respiratory medicine specialists in rising to the challenge of the chronic patient&#46; They conclude that the only appropriate approach would be to adapt the guidelines and recommendations of the scientific societies to strategies designed for the care of the chronic patient&#46; Taking COPD as a prime example of a chronic disease in which a very high proportion of patients present comorbidities&#44; a patient stratification model based on the Spanish guidelines for the treatment of COPD is proposed&#46; In this model&#44; 4 levels of complexity are defined&#44; from which the appropriate care requirements for each level can be established&#44; ranging from health awareness and disease prevention in the at-risk population to diagnostic and self-care programs&#46; Management recommendations range from disease management in less complex cases to case management in the more complicated population&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In Soler-Catalu&#241;a&#39;s proposal the role of integrated healthcare processes&#44; in which the figure of the nurse case manager and the primary care team are essential&#44; is preserved&#46; Nevertheless&#44; the authors make it clear that pulmonologists will have to play a central role&#44; both in establishing population stratification criteria and in their direct involvement in the care of moderately to highly complex cases&#44; for reasons of both quality and efficiency&#46; This conclusion is applicable not only to COPD&#44; but also to the management of other chronic diseases such as asthma&#44; bronchiectasis and respiratory failure which generate high costs in terms of resources&#44; and have a high impact on morbidity and health-related quality of life&#46;</p></span>"
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Editorial
Aging, Chronicity and Pulmonary Care
Envejecimiento, cronicidad y atención neumológica
Pilar de Lucas-Ramos
Corresponding author
pilar.delucas@gmail.com

Corresponding author.
, Jose Miguel Rodriguez Gonzalez-Moro
Servicio de Neumología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Over the last 60 years&#44; we have witnessed a gradual change in the typical individual seeking healthcare&#46; Our patient populations are now characterized by advancing age&#44; increased incidence of chronic diseases&#44; and a high prevalence of pluripathology&#46; While it is true that chronic diseases can develop at any time during a patient&#39;s lifetime&#44; these 3 features are closely interrelated&#44; so it is equally true that their prevalence increases with advancing age&#46; The same occurs with the development of comorbidities&#46; In the specific case of the lung&#44; aging is associated with genomic instability and epigenetic changes that are key factors in the development of chronic lung diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> According to the World Health Organization &#40;WHO&#41;&#44; chronic diseases account for over 60&#37; of all deaths worldwide&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> Add to this the impact of these diseases on patient and caregivers&#8217; quality of life&#44; years of life lost&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> the economic burden and the costs of healthcare resources&#44; and it is easy to understand how the care of chronic patients may be a major challenge for healthcare providers&#46; The duty of these bodies is to achieve the best quality of care in chronicity&#44; while continuing to offer the same level of care to acute cases&#46; Improvements in social and healthcare standards mean that Spain is now among the countries with the longest life expectation worldwide&#44; but the outcome of this is an increase in elderly subjects with chronic diseases&#46; Chronic diseases currently account for 80&#37; of consultations in primary care centers and 60&#37; of hospital stays&#44; particularly with respect to unscheduled admissions&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> It is estimated that by 2050&#44; 35&#37; of our population will be older than 75 years&#44; so an exponential increase in the rate of chronic disease is only to be expected&#46; The care of patients with chronic diseases&#44; therefore&#44; will be one of the most important challenges to be faced by the Spanish healthcare system in coming years&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The WHO has called on governments to introduce measures based on 3 key elements&#58; mapping chronic diseases and social&#44; economic&#44; behavioral and political factors&#59; reducing exposure to risk factors&#59; and reinforcing healthcare provisions&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> The implementation of specifically designed models for caring for populations with chronic diseases has been shown to be an efficient approach in various healthcare systems&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">6&#44;7</span></a> These models&#44; the most widely known of which is the Chronic Care Model &#40;CCM&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a> advocate a proactive approach&#44; with a patient-centered&#44; participative&#44; multidisciplinary team with well-defined roles&#44; in which shared decision-making is based on scientific evidence and on the preferences of the patient and their family members&#46; An essential aspect of this approach is the availability of efficient information systems&#46; The CCM&#44; in particular&#44; introduced the concepts of integrated care&#44; disease management and case management&#46; Another reference in the management of chronic care patients is the populational model known as &#8220;Kaiser Permanente&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> This system stratifies the population as a pyramid&#44; so that the complexity of care can be adapted to the needs of each stratum or level&#46; Both types of model can be taken as complementary&#44; in line with the WHO&#39;s proposal for the development of an Innovative Care for Chronic Conditions Framework&#44; in which 5 building blocks are specified&#58; populational health approach&#44; awareness and prevention of chronic disease&#44; patient responsibility and autonomy&#44; continuity of care&#44; and interventions tailored to patient needs&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Just 3 years ago&#44; the Ministry of Health&#44; Social Policy and Equality published a document entitled &#8220;A strategic approach to chronicity in the National Healthcare System&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">4</span></a> According to this document&#44; chronicity must be approached from a multidisciplinary perspective&#44; to ensure continuity of care and the full participation of the patient and their family&#47;caregivers&#46; In this model&#44; primary care teams logically play a key role as the hub for coordinating care&#46; Nevertheless&#44; it is surprising that scientific societies and specialists involved in the care of the most common chronic diseases&#44; such as pulmonologists &#40;COPD and chronic respiratory failure&#41;&#44; cardiologists &#40;heart failure&#41;&#44; or endocrinologists &#40;diabetes mellitus&#41; were not involved in the preparation of these recommendations&#46; Before this strategy was published&#44; autonomous communities&#44; such as the Basque Country or Catalonia had already set down guidelines for the care of chronic conditions&#46; Subsequently&#44; strategic plans to develop community-specific programs were published by the remaining autonomous communities of Spain&#46; However&#44; the models are very far from uniform&#44; and while in Madrid the involvement of different specialists is more notable&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> other communities follow the general&#44; national model&#46; Under the pretext of providing a more integrated approach to care in these patients&#44; their aim is to focus on the internist as the central figure in patient management in hospitals&#44; and on the family doctor in outpatient care&#46; The role of the specialist is vague and relegated to the sidelines&#44; a factor that can considerably undermine the quality of care&#46; The significant progress in healthcare achieved by Spain in recent decades&#44; it should be noted&#44; is due to major advances in specialty care and therapeutic and diagnostic techniques&#44; and in this time the &#8220;generalist&#8221; healthcare system has given way to a &#8220;specialized&#8221; system&#46; However&#44; the approach to chronic disease in the new care models amounts to a step backwards rather than forwards&#44; motivated by the pursuit of theoretical savings&#44; doubtless due to an incomplete analysis of the problem&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">A patient is usually classified as &#8220;chronic&#8221; when he or she presents chronic disease in a single organ&#46; Even in those cases in which other&#44; more or less important comorbidities are present&#44; the role of the specialist physician caring for the main chronic disease and their collaboration with other specialists&#44; with the family doctor&#44; nursing staff and the social services&#44; is essential&#46; In this model&#44; the chronic patient is confused with the pluripathological patient&#44; which is a serious mistake&#44; since the same criteria are applied in both cases&#44; when the approach should be different&#46; There is no doubt that any chronicity strategy must ensure continuity of care&#44; and instruments and algorithms for coordinating various healthcare levels and the social services must be designed for this purpose&#46; This does not&#44; however&#44; mean ignoring the major role of the specialist who is most aware of all aspects of the disease&#44; and who must&#44; of necessity&#44; direct the care strategy&#46; Primary care and specialist inpatient and outpatient medicine must work hand in hand to achieve continuity of care for the patient&#46; In this context&#44; the nurse case manager and the provision of adequate social support are of particular importance&#46; Integrated care is essential&#44; but without sacrificing scientific and technical quality&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In this respect&#44; the highly interesting article published in this issue of <span class="elsevierStyleItalic">Archivos de Bronconeumolog&#237;a</span> by Dr&#46; Soler-Catalu&#241;a et al&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> could not have come at a better time&#46; The authors have clarified and evaluated what might be the role of respiratory medicine specialists in rising to the challenge of the chronic patient&#46; They conclude that the only appropriate approach would be to adapt the guidelines and recommendations of the scientific societies to strategies designed for the care of the chronic patient&#46; Taking COPD as a prime example of a chronic disease in which a very high proportion of patients present comorbidities&#44; a patient stratification model based on the Spanish guidelines for the treatment of COPD is proposed&#46; In this model&#44; 4 levels of complexity are defined&#44; from which the appropriate care requirements for each level can be established&#44; ranging from health awareness and disease prevention in the at-risk population to diagnostic and self-care programs&#46; Management recommendations range from disease management in less complex cases to case management in the more complicated population&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In Soler-Catalu&#241;a&#39;s proposal the role of integrated healthcare processes&#44; in which the figure of the nurse case manager and the primary care team are essential&#44; is preserved&#46; Nevertheless&#44; the authors make it clear that pulmonologists will have to play a central role&#44; both in establishing population stratification criteria and in their direct involvement in the care of moderately to highly complex cases&#44; for reasons of both quality and efficiency&#46; This conclusion is applicable not only to COPD&#44; but also to the management of other chronic diseases such as asthma&#44; bronchiectasis and respiratory failure which generate high costs in terms of resources&#44; and have a high impact on morbidity and health-related quality of life&#46;</p></span>"
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ISSN: 15792129
Original language: English
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