BackgroundApproximately 210 million people are estimated to have chronic obstructive pulmonary disease [COPD] worldwide. The burden of disease is known to be high, though less is known about those of a younger age. The aim of this study was to investigate the wider personal, economic and societal burden of COPD on a cross country working-age cohort.MethodsA cross-country [Brazil, China, Germany, Turkey, US, UK] cross-sectional survey methodology was utilised to answer the research questions. 2426 participants aged 45-67 recruited via a number of recruitment methods specific to each country completed the full survey. Inclusion criteria were a recalled physician diagnosis of COPD, a smoking history of > 10 pack years and the use of COPD medications in the previous 3 months prior to questioning. The survey included items from the validated Work Productivity and Activity Impairment [WPAI] scale and the EuroQoL 5 Dimension [EQ-5D] scale. Disease severity was measured using the 5-point MRC [Medical Research Council] dyspnoea scale as a surrogate measure.Results64% had either moderate [n = 1012] or severe [n = 521] COPD, although this varied by country. 75% of the cohort reported at least one comorbid condition. Quality of life declined with severity of illness [mild, mean EQ-5D score = 0.84; moderate 0.58; severe 0.41]. The annual cost of healthcare utilisation [excluding treatment costs and diagnostic tests] per individual was estimated to be $2,364 [£1,500]. For those remaining in active employment [n: 677]: lost time from work cost the individual an average of $880 [£556] per annum and lifetime losses of $7,365 [£4,661] amounting to $596,000 [£377,000] for the cohort. 447 [~40%] of the working population had retired prematurely because of COPD incurring individual estimated lifetime income losses of $316,000 [£200,000] or a combined total of $141 m [£89.6 m]. As the mean age of retirees was 58.3 and average time since retirement was 4 years, this suggests the average age of retirement is around 54. This would mean a high societal and economic impact in all study countries, particularly where typical state retirement ages are higher, for example in Brazil, Germany and the UK [65] and the US [65,66,67], compared to Turkey [58 for women, 60 for men] and China [60].ConclusionsAlthough generalisation across a broader COPD population is limited due to the varied participant recruitment methods, these data nevertheless suggest that COPD has significant personal, economic and societal burden on working age people. Further efforts to improve COPD diagnosis and management are required.

As the number of individuals with chronic illness increases so has the need for strategies to enable nurses to engage them effectively in daily management of their conditions. Shared decision making between patients and nurses is one approach frequently discussed in the literature. This paper reviews recent studies of shared decision making and the meaning of findings for the nurse-patient relationship. Patients likely to prefer to engage in shared decision making are younger and have higher levels of education. However, there is a lack of evidence for the effect of shared decision making on patient outcomes. Further, studies are needed to examine shared decision making when the patient is a child. Nurses are professionally suited to engage their patients fully in treatment plans. More evidence for how shared decision making affects outcomes and how nurses can successfully achieve such engagement is needed.

IMPORTANCE Clinicians use probability estimates to make a diagnosis. Teaching students to make more accurate probability estimates could improve the diagnostic process and, ultimately, the quality of medical care. OBJECTIVE To test whether novice clinicians can be taught to make more accurate bayesian revisions of diagnostic probabilities using teaching methods that apply either explicit conceptual instruction or repeated examples. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial of 2 methods for teaching bayesian updating and diagnostic reasoning was performed. A web-based platform was used for consent, randomization, intervention, and testing of the effect of the intervention. Participants

Health care providers play a key role in promoting and participating in asthma coalition activities. Barriers to participation include lack of time, concern about coalition effectiveness, and unfamiliarity with community-based approaches to health issues. Despite this, the Allies Against Asthma coalitions were successful at involving health care providers in leadership roles, on advisory committees, and as research and clinical experts. Successful engagement strategies included presentation of data illustrating need for improved asthma care, identification of clinicians who were involved in caring for children with uncontrolled asthma, and education regarding the added value of a coalition and benefits of participation. Despite barriers to participation, health care providers felt that their participation in asthma coalitions helped them to develop collaborative relationships with other agencies, increase their professional knowledge and skills with regard to asthma management, and improve access to priority populations.

Activities addressing pediatric asthma are often fragmented. Allies coalitions promoted integration, the alignment of concurrent asthma control activities across and within sectors. Systems integration describes activities from an organizational perspective. Activities included developing a shared vision, promoting consistency in asthma education and self-management support, improving adherence to clinical guidelines, advocating jointly for policy change, and seeking funds collaboratively. Service integration describes activities focused on ensuring seamless, comprehensive services through coordination within and across organizations. Activities included use of community health workers (CHWs) and nurses for care coordination, program cross-referral, and clinical quality improvement. Integration is a sustainable role for coalitions as it requires fewer resources than service delivery and results in institutionalization of system changes. Organizations that seek integration of asthma control may benefit.

School nurses play a critical role in the management of children's asthma, yet they face barriers in their efforts to deliver quality care. In this qualitative study involving focus groups with school nurses, we identified key barriers in order to inform best practices. School nurses identified 4 main barriers to effective asthma care in elementary schools: lack of education, lack of communication, lack of resources, and lack of respect. An analysis of the barriers suggests that best practices for asthma care in elementary school settings require collaborative strategies that involve schools, families, the community, and the healthcare profession.

Today, about 5 million children in the United States-one in every 15 children under the age of 18-have asthma. The social and economic costs of childhood asthma are high. Asthma management requires a multifaceted approach, including partnerships among physicians, school nurses, and parents to create a continuum of care that is often missing from conventional health-care delivery systems. At a local level, coalitions are an important strategy for promoting partnerships for the management of asthma. Focus groups were conducted in the Hampton Roads region of southeastern Virginia to provide in-depth information about barriers to the management of asthma. The perspectives of physicians, school nurses, and parents who live in areas characterized as having unusually high rates of emergency department visits or hospitalizations for asthma were included. This paper presents an in-depth analysis of the qualitative data obtained from these focus groups. (Pediatr Asthma Allergy Immunol 2004;17[1]:25-35.)

BackgroundChronic Obstructive Pulmonary Disease (COPD) has significant effects on individuals, their families and society although the impact of COPD on a working population is not well understood. In a large, international study ('COPD Uncovered') we investigated the consequences of COPD on patients, families and society. Here we report descriptive results from a subset of these data, showing the impact of COPD on patients' work productivity, absenteeism, earnings, activity impairment, lifestyle and ability to plan for the future. Methods A cross-sectional survey was undertaken in Germany, USA, UK (telephone interviews), China and Turkey (face-to-face interviews) and Brazil (telephone and face-to-face interviews). The questionnaire was developed around established instruments and included the Work Productivity and Activity Impairment questionnaire (WPAI) as well as additional questions on the impact of COPD on income and lifestyle. Participants were aged between 45-67 years, with a diagnosis of COPD. Disease severity was measured using the MRC dyspnoea scale (mild=1-2; moderate=3-4; severe=5). ResultsThe sample included 2426 respondents (49% male, 51% female), age ranges (45-49 years (23%), 50-59 (38%) and 60-68 (39%)) balanced evenly across the six countries. 35% of participants had mild COPD, 42% moderate and 22% severe. Impact on work and lifestyle are shown in the table.