Original article
Influence of inhalation device, active substance, and drug formulation on the compliance of patients with obstructive pulmonary diseases. A physicians... perspective
S.G. Theodorakisa, G. Koliosb, V. Tzilasc, D. Bourosc,...
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debouros@med.uoa.gr
dbouros@med.uoa.gr
Corresponding author at: Medical School, National and Kapodistrian University of Athens, Athens Medical Center, Kifisias 58, Marousi 15125, Athens, Greece.
dbouros@med.uoa.gr
Corresponding author at: Medical School, National and Kapodistrian University of Athens, Athens Medical Center, Kifisias 58, Marousi 15125, Athens, Greece.
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Zhou, F. Bai, X. Li, G. Zhou, X. Tian, G. Li, Y. Zhang, X. Zhou, D. Xu, Y. Ding" "autores" => array:10 [ 0 => array:2 [ "nombre" => "Y." "apellidos" => "Zhou" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Bai" ] 2 => array:2 [ "nombre" => "X." "apellidos" => "Li" ] 3 => array:2 [ "nombre" => "G." "apellidos" => "Zhou" ] 4 => array:2 [ "nombre" => "X." "apellidos" => "Tian" ] 5 => array:2 [ "nombre" => "G." "apellidos" => "Li" ] 6 => array:2 [ "nombre" => "Y." "apellidos" => "Zhang" ] 7 => array:2 [ "nombre" => "X." "apellidos" => "Zhou" ] 8 => array:2 [ "nombre" => "D." "apellidos" => "Xu" ] 9 => array:2 [ "nombre" => "Y." 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"apellidos" => "Theodorakis" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:3 [ "nombre" => "G." "apellidos" => "Kolios" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "V." "apellidos" => "Tzilas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:4 [ "nombre" => "D." "apellidos" => "Bouros" "email" => array:2 [ 0 => "debouros@med.uoa.gr" 1 => "dbouros@med.uoa.gr" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "..." "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Chiesi Hellas AEBE, Pharmaceutical Company, Athens Greece" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Laboratory of Pharmacology, Faculty of Medicine, Democritus University of Thrace, Alexandroupolis, Greece" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Interstitial Lung Disease Unit, 1st Dept of Pneumonology, Medical School, National and Kapodistrian University, Athens, Greece" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "..." "correspondencia" => "Corresponding author at: Medical School, National and Kapodistrian University of Athens, Athens Medical Center, Kifisias 58, Marousi 15125, Athens, Greece." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1334 "Ancho" => 2175 "Tamanyo" => 204096 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Evaluation of parameters influencing the compliance of patients with COPD. Mean and Median of the seven Parameters: Scale: 1= most important, 7= least important.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Obstructive airway diseases, Chronic Obstructive Pulmonary Disease (COPD) and Asthma, are increasing in frequency throughout the world, having a significant impact on quality of life. More than 3 million people died of COPD in 2012 accounting for 6% of all deaths globally.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Similarly, the global prevalence rates of asthma in adults is increasing.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Compliance plays a major role in disease outcome, as it has been associated with increased morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> A better understanding of the factors associated with adherence, can lead to more appropriate decisions regarding management. It has been shown that treatment success is proportionally linked to patients... compliance, both in COPD and asthma.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> On the other hand, suboptimal adherence to inhaled medication is linked to increased hospitalizations and economic health costs.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7...10</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The present study surveyed doctors... perspective on the role of active substance, type of inhalation device, onset of action, drug formulation, duration of action and adverse events as parameters influencing patients... compliance.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Participants</span><p id="par0020" class="elsevierStylePara elsevierViewall">A total of 144 prescribing doctors participated in the study with the majority being pulmonologists. Specifically, there were 104 pulmonologists (72%), 3 intensivists, 7 allergologists, 27 internists & 3 pediatricians) participated in the study. Excluding the 3 pediatricians, all other participants declared that were actively involved in the management of COPD and asthma. Regarding the workplace of respondents, 74% worked in a public hospital, 19% in a private practice and 7% in a private clinic.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Design of the study</span><p id="par0025" class="elsevierStylePara elsevierViewall">During the National Respiratory Congress, physicians were asked to answer a questionnaire regarding the importance of device and substance characteristics influencing the compliance of patients with chronic obstructive airways diseases. The importance of parameters was evaluated on a scale of 1...6, with one representing the most and six representing the least important. Evaluated parameters included rapid onset of action, duration of action, ease of use, low flow resistance, ability of the device to confirm the dose, type of inhalation device, and the formulation of the drug. Participants were asked to determine the importance of the above-mentioned parameters in chronic obstructive lung diseases in general and subsequently in COPD and asthma separately. The average time to complete the questionnaire was 12...min.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Statistical analysis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Descriptive statistics: The continuous (e.g. age) and ordinal study parameters (e.g. the scaled answers to the Study questions) were presented using mean, median, standard deviation (SD), standard error of the mean (SE) and range, while the nominal parameters (e.g. gender) were presented using tables of frequencies.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Inference: The data analysed were subjective rankings (scores) by the physicians, on various parameters (characteristics) of inhalation devices. In the case of Question 1 (overall evaluation of parameters influencing patients... compliance/ 6 parameters) the data were ranked on a six-point scale. In the case of Question 2A (parameters influencing the compliance of patients with Asthma / 7 parameters) and Question 2B (parameters influencing COPD patients... compliance / 7 parameters) the data were ranked on a seven-point scale.</p><p id="par0040" class="elsevierStylePara elsevierViewall">All above parameters were compared between male and female physicians using Mann-Whitney U-test, while they were compared between age groups using Kruskal Wallis test.</p><p id="par0045" class="elsevierStylePara elsevierViewall">For the parameters belonging to Question 1 (overall evaluation of parameters influencing patients... compliance /6 parameters), Friedman...s test checked the overall difference between scores, i.e. if at least one of the parameters had a different score from the rest. Afterwards these six parameters were compared with each other using Wilcoxon signed-rank test (15 comparisons). Bonferroni correction was also applied, so the alpha level (two-tailed) for these comparisons was set at 0.05/15...=...0.0033.</p><p id="par0050" class="elsevierStylePara elsevierViewall">For the (scaled) parameters belonging to Question 2A (parameters influencing the compliance of patients with Asthma / 7 parameters), Friedman...s test checked the overall difference between scores, i.e. if at least one of the parameters had a different score from the rest. Afterwards the seven parameters were compared with each other using Wilcoxon signed-rank test (21 comparisons). Again, Bonferroni correction was applied, so the alpha level (two-tailed) for these comparisons was set at 0.05/21...=...0.0024. The same procedure as above was applied (the alpha level [two-tailed] for these comparisons was set at 0.05/21...=...0.0024) for the scaled parameters belonging to Question 2B (parameters influencing the compliance of patients with COPD / 7 parameters). Finally, the parameters influencing COPD and Asthmatic patients... compliance were compared between patients with Asthma (Question 2A) and COPD patients (Question 2B) using Wilcoxon signed-rank test (7 comparisons). No Bonferroni adjustment was applied since these comparisons were independent. All analyses were performed using R 4.0.3.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Results</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Overall evaluation of parameters influencing patients... compliance</span><p id="par0055" class="elsevierStylePara elsevierViewall">On average ..úRapid onset of action..Ñ was ranked lower (more important- influential) than all the other parameters. It was statistically significantly lower than all other parameters except that of ..úType of inhalation device..Ñ. On the contrary, ..úAdverse events..Ñ was ranked statistically significantly higher (less important- influential) than all the other parameters. (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Statistical significance among studied parameters is shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Parameters influencing the compliance of patients with Asthma</span><p id="par0060" class="elsevierStylePara elsevierViewall">On average ..úRapid onset of action..Ñ was ranked statistically significantly lower (more important-influential) than all the other parameters. The next most influential parameters were ..úEase of use..Ñ and ..úDuration of action..Ñ that were ranked statistically significantly lower (more important- influential) than the other 4 parameters. On the contrary, ..úThe formulation of the drug..Ñ was ranked statistically significantly higher (less important) than all other parameters. (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Statistical significance among studied parameters is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Parameters influencing the compliance of patients with COPD</span><p id="par0065" class="elsevierStylePara elsevierViewall">On average ..úRapid onset of action..Ñ, ..úDuration of action..Ñ and ..úEase of use..Ñ were ranked statistically significantly lower (more important-influential) than the other four parameters (..úRapid onset of action..Ñ, ..úDuration of action..Ñ and ..úEase of use..Ñ were not statistically significantly differentiated between each other). The parameter ..úThe formulation of the drug..Ñ was ranked statistically significantly higher (less important) than all other parameters, except that of ..úAbility of the device to confirm the dose..Ñ.</p><p id="par0070" class="elsevierStylePara elsevierViewall">(<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). Statistical significance among studied parameters is shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Comparison of parameters influencing the compliance between patients with COPD and asthma</span><p id="par0075" class="elsevierStylePara elsevierViewall">The following parameters were differentiated in the comparison between patients with Asthma and COPD patients,: Rapid onset of action was ranked statistically significantly lower (more important-influential) in Asthmatic patients, Low flow resistance was ranked statistically significantly higher (less important-influential) in Asthmatic patients, duration of action and ease of use were marginally statistically significantly higher (less important-influential) in Asthmatic patients (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Discussion</span><p id="par0080" class="elsevierStylePara elsevierViewall">In this study surveying the opinion of physicians treating patients with chronic obstructive airways diseases (asthma and COPD), rapid onset of action, ease of use and duration of action were the most important parameters favoring patients... compliance for both diseases.</p><p id="par0085" class="elsevierStylePara elsevierViewall">As expected, rapid onset of action was the most important factor influencing compliance both in COPD and asthma. Interestingly, it was statistically more important in asthma than in COPD. This finding reflects the difference in pathophysiology and clinical behavior between asthma in COPD as perceived by physicians. In general, asthma is considered a disease which is more likely to be complicated with episodes of acute shortness of breath in need of immediate relief. Duration of action was also considered as an important parameter influencing compliance, irrespective of the underlying diagnosis. This parameter was numerically more important in COPD compared to asthma. Duration of action is clinically relevant for bronchodilators as their duration of action has a direct impact on patients... symptoms and therefore compliance. The above physicians views also correlate with patients... perspectives.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The fact that adverse events were not considered at all as an important compliance factor, confirms the strong belief of physicians in the safety of inhaled medications. Ease of use was also considered as a key factor for compliance. In asthma ease of use is especially important during an acute event of dyspnea needing immediate relief. In COPD patients, who are usually older with several comorbidities ease of use is also an understandable parameter that can affect compliance.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The increased number of inhaler devices in recent years has resulted in a confusing number of choices for physicians and patients. The prescribing physician must balance the efficacy of inhaled medications with patients... preferences, personality traits and their physical ability to handle devices appropriately. The selection of an inhalation device for patients with asthma and COPD has become a complicated issue as several parameters should be taken into account, such as: device/drug availability, clinical setting, patient age, the ability to use the selected device correctly, device use with multiple medications, cost and reimbursement, drug administration time, convenience in both outpatient and inpatient settings, and physician and patient preference, as stated previously.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12...16</span></a> Unfortunately, such studies are scarce in the literature.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Strengths of this study are the detailed questionnaire, and the relatively high number of respondents. However, we acknowledge certain limitations of the study. First, we recognize that we explored a complex issue which is difficult to approach by "one- shot strong and direct answers..Ñ as the answers do not take into account the individualization of the patient path, the level of functional severity, the different phenotypes, the age of the patient and the patient's history. Another limitation is that this study exclusively included specialists and lacks the views of general practitioners. Thus, the results cannot be generalized for non-specialists. Furthermore, the study reflects the beliefs of the physicians of a single country and comparative studies among different countries could provide significant insights. Given the limited number of relevant studies, the present work adds to our understanding of physicians... perspectives on patient compliance.</p><p id="par0100" class="elsevierStylePara elsevierViewall">In conclusion, rapid onset of action, ease of use and duration of action, were classified higher among the parameters examined. Further studies are needed among physicians of different specialties and nationalities to identify more rigorously factors increasing patient compliance. Evidence-based guidelines for the selection of the appropriate inhalation device in specific clinical settings are needed.</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">All authors have no conflicts of interest to disclose.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres1827567" "titulo" => "Abstract" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1593517" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 3 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Participants" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Design of the study" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Statistical analysis" ] ] ] 4 => array:3 [ "identificador" => "sec0030" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0035" "titulo" => "Overall evaluation of parameters influencing patients... compliance" ] 1 => array:2 [ "identificador" => "sec0040" "titulo" => "Parameters influencing the compliance of patients with Asthma" ] 2 => array:2 [ "identificador" => "sec0045" "titulo" => "Parameters influencing the compliance of patients with COPD" ] 3 => array:2 [ "identificador" => "sec0050" "titulo" => "Comparison of parameters influencing the compliance between patients with COPD and asthma" ] ] ] 5 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-07-07" "fechaAceptado" => "2020-11-23" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1593517" "palabras" => array:4 [ 0 => "Inhalation device" 1 => "Compliance" 2 => "COPD" 3 => "Asthma" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Aim</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">To investigate the perspective of physicians treating chronic airway diseases on the importance of device and substance characteristics influencing the compliance of patients with chronic obstructive airways diseases.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">We surveyed physicians... perspective on the impact of device and substance characteristics on patients... compliance.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Methods</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">This study was carried out by running a structured questionnaire, to a total of 144 physicians, conducting personal interviews and evaluating answers on a scale from 1 for most to 6 for least important influencing parameter.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Results</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Overall, the most important parameters influencing patients... compliance according to physicians... perspective were rapid onset of action, type of inhalation device and duration of action. Adverse events were considered as the least important parameter. When COPD and asthma were examined separately, the most important parameters influencing compliance were rapid onset of action, ease of use and duration of action. Rapid onset of action was significantly more important in asthma than COPD.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Conclusion</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Onset and duration of action and ease of use were classified higher as important parameters to increase patients... compliance, according to physicians... perspective.</p></span>" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Methods" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Results" ] 4 => array:2 [ "identificador" => "abst0025" "titulo" => "Conclusion" ] ] ] ] "multimedia" => array:11 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1247 "Ancho" => 2167 "Tamanyo" => 118017 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Overall evaluation of parameters influencing patients... compliance. Mean and Median of the six evaluated parameters: Scale: 1= most important, 6= least important.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1251 "Ancho" => 2175 "Tamanyo" => 198592 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Evaluation of parameters influencing the compliance of patients with Asthma. Mean and Median of the seven Parameters: Scale: 1= most important, 7= least important.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1334 "Ancho" => 2175 "Tamanyo" => 204096 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Evaluation of parameters influencing the compliance of patients with COPD. Mean and Median of the seven Parameters: Scale: 1= most important, 7= least important.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Note: P-values that were marginally ...0.0033 are marked with blue colour, while p-values <0.0033 (Statistically significant difference between the two parameters) are marked with yellow colour.</p>" "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202301030817466091"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3078853.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Descriptive statistics regarding the six Parameters of Question 1: Overall evaluation of parameters influencing patients... compliance. Scale: 1...=...1st most important, 6...=...6th least important. P-values of the 15 applications of Wilcoxon signed-rank test. Base: Observed cases.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Note: P-values<0.0024 (Statistically significant difference between the two parameters) are marked with yellow colour.</p>" "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202301030817466092"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3078850.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Descriptive statistics regarding the seven Parameters influencing the compliance of patients with Asthma. Scale: 1...=...1st most important, 7...=...7th least important. P-values of the 21 applications of Wilcoxon signed-rank test. Base: Observed cases (N...=...140).</p>" ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Note: P-values<0.0024 (Statistically significant difference between the two parameters) are marked with yellow colour.</p>" "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202301030817466093"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3078851.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Descriptive statistics regarding the seven parameters influencing the compliance of patients with COPD. Scale: 1...=...1st most important, 7...=...7th least important. P-values of the 21 applications of Wilcoxon signed-rank test. Base: Observed cases (N...=...138).</p>" ] ] 6 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Note: P-values marginally <0.05 are marked with blue colour, while p-values <0.005 are marked with yellow colour.</p>" "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=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><elsevierMultimedia ident="202301030817466094"></elsevierMultimedia> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3078852.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Mean and Median values regarding the seven Parameters influencing the compliance of patients with ASTHMA/ COPD. P-values of the 7 applications of Wilcoxon signed-rank test. Base: Observed cases (N...=...138).</p>" ] ] 7 => array:5 [ "identificador" => "202301030817466091" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 2663 "Ancho" => 2917 "Tamanyo" => 550806 ] ] ] 8 => array:5 [ "identificador" => "202301030817466092" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx2.jpeg" "Alto" => 2979 "Ancho" => 2917 "Tamanyo" => 700284 ] ] ] 9 => array:5 [ "identificador" => "202301030817466093" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx3.jpeg" "Alto" => 2544 "Ancho" => 2917 "Tamanyo" => 701033 ] ] ] 10 => array:5 [ "identificador" => "202301030817466094" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx4.jpeg" "Alto" => 1095 "Ancho" => 2500 "Tamanyo" => 252954 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "COPD Guidelines: A Review of the 2018 GOLD Report" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 5 | 14 |
| 2024 October | 39 | 34 | 73 |
| 2024 September | 35 | 24 | 59 |
| 2024 August | 57 | 30 | 87 |
| 2024 July | 44 | 33 | 77 |
| 2024 June | 63 | 36 | 99 |
| 2024 May | 39 | 35 | 74 |
| 2024 April | 40 | 34 | 74 |
| 2024 March | 37 | 28 | 65 |
| 2024 February | 34 | 32 | 66 |
| 2024 January | 48 | 30 | 78 |
| 2023 December | 25 | 18 | 43 |
| 2023 November | 53 | 63 | 116 |
| 2023 October | 56 | 36 | 92 |
| 2023 September | 44 | 47 | 91 |
| 2023 August | 34 | 23 | 57 |
| 2023 July | 34 | 27 | 61 |
| 2023 June | 25 | 14 | 39 |
| 2023 May | 41 | 51 | 92 |
| 2023 April | 31 | 31 | 62 |
| 2023 March | 91 | 41 | 132 |
| 2023 February | 106 | 59 | 165 |
| 2023 January | 120 | 69 | 189 |
| 2022 December | 87 | 36 | 123 |
| 2022 November | 47 | 42 | 89 |
| 2022 October | 121 | 41 | 162 |
| 2022 September | 35 | 36 | 71 |
| 2022 August | 40 | 33 | 73 |
| 2022 July | 65 | 59 | 124 |
| 2022 June | 39 | 27 | 66 |
| 2022 May | 43 | 38 | 81 |
| 2022 April | 39 | 36 | 75 |
| 2022 March | 39 | 55 | 94 |
| 2022 February | 36 | 42 | 78 |
| 2022 January | 45 | 47 | 92 |
| 2021 December | 37 | 36 | 73 |
| 2021 November | 37 | 41 | 78 |
| 2021 October | 55 | 75 | 130 |
| 2021 September | 38 | 37 | 75 |
| 2021 August | 39 | 40 | 79 |
| 2021 July | 40 | 22 | 62 |
| 2021 June | 59 | 48 | 107 |
| 2021 May | 50 | 52 | 102 |
| 2021 April | 107 | 86 | 193 |
| 2021 March | 70 | 41 | 111 |
| 2021 February | 56 | 30 | 86 |
| 2021 January | 76 | 33 | 109 |
| 2020 December | 5 | 2 | 7 |
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