Artigo Malnutrition and obesity DPOC

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RESEARCH PAPER
Malnutrition and obesity: influence in mortality and
readmissions in chronic obstructive pulmonary disease
patients
A. Zapatero,* R. Barba,† J. Ruiz,* J. E. Losa,‡ S. Plaza,§ J. Canora* & J. Marco¶
*Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Madrid, Spain
†Servicio de Medicina Interna, Hospital Rey Juan Carlos, Madrid, Spain
‡Servicio de Medicina Interna, Hospital Universitario Fundaci�on Alcorc�on, Madrid, Spain
§Servicio de Medicina Interna, Hospital Severo Ochoa, Madrid, Spain
¶Servicio de Medicina Interna, Hospital Cl�ınico de San Carlos, Madrid, Spain
Keywords
COPD, malnutrition, mortality, obesity paradox,
readmissions.
Correspondence
R. Barba, Hospital Rey Juan Carlos, Calle Gladiolo
s/n nº 2, 28981 Parla, Madrid, Spain.
Tel.: +349 1191 3555
Fax: +341 913 292
E-mail: raquel.barba@hospitalreyjuancarlos.es
How to cite this article
Zapatero A., Barba R., Ruiz J., Losa J.E., Plaza S.,
Canora J. & Marco J. (2013) Malnutrition and
obesity: influence in mortality and readmissions in
chronic obstructive pulmonary disease patients.
J Hum Nutr Diet.
doi:10.1111/jhn.12088
Abstract
Background: The present study aimed to assess the association of obesity
and malnutrition with the mortality of hospitalised patients with acute exac-
erbation of chronic obstructive pulmonary disease (COPD) and the risk of
readmission in <30 days.
Methods: A retrospective chart review of consecutive patients admitted with
COPD as the primary reason for discharge in Spain between 1 January 2006
and 31 December 2007 was performed. Patients with a diagnosis of obesity
or malnutrition in the hospital discharge clinical report were identified. The
in-hospital mortality and re-admittance 30 days after discharge indices of
obese and malnourished patients were compared against the subpopulation
without these diagnoses.
Results: Of the 313 233 COPD admittances analysed, there were 22 582
(7.2%) diagnoses of obesity and 6354 (2.0%) diagnoses of malnutrition. In-
hospital global mortality and the re-admittance risk were 12.0% and 16.7%,
respectively. Obese patients showed a lower in-hospital mortality risk [odds
ratio (OR) = 0.52; 95% confidence interval (CI) = 0.49–0.55] and early re-
admittance risk (OR = 0.87; 95% CI = 0.85–0.92) compared to non-obese
patients. Malnourished patients had a much higher risk of death when in
hospital (OR = 1.73; 95% CI = 1.62–1.85) or of being re-admitted within
30 days after discharge (OR = 1.29; 95% CI = 1.22–1.38), even after adjust-
ing for possible confounding factors.
Conclusions: Obesity in patients hospitalised for COPD substantially
reduces in-hospital mortality risk and the possibility of early re-admittance.
Malnutrition is associated with an important increase in in-hospital mortal-
ity and risk of re-admittance in the 30 days following discharge.
Introduction
Chronic obstructive pulmonary disease (COPD) is a
major global health problem. It is the fourth-leading
cause of death in the USA and is projected to be the
third-leading cause of death worldwide by 2020 (Murray
& Lopez, 1996; McGhan et al., 2007) affecting 4–9% of
the adult population (Marti et al., 2006). Exacerbations
of COPD disease comprise an important component of
the burden of the disease by accelerating lung function
decline, precipitating poor health status (Seemungal et al.,
1998), increasing healthcare costs (Andersson et al., 2002)
and negatively affecting survival (Connors et al., 1996) .
Obesity is increasing dramatically throughout the Wes-
tern world and is common in patients with COPD
(Franssen et al., 2008; Ora et al., 2009). It is widely
ª 2013 The British Dietetic Association Ltd. 1
Journal of Human Nutrition and Dietetics
accepted that obesity in the general population is associ-
ated with increased mortality and greater disease risk.
However, in those who have experienced major illness or
chronic disease, it appears that obesity is associated with
improved survival. This ‘obesity paradox’ has been dem-
onstrated in several recent studies of critically and chroni-
cally ill patients, as well as in patients undergoing certain
procedures, suggesting that overweight and obese patients
may have better outcomes than normal weight patients
(Fleischmann et al., 1999; Gurm et al., 2002; Kalantar-
Zadeh et al., 2003; Lee et al., 2004; Marik, 2006; Fonarow
et al., 2007; Barba et al., 2008; Mullen et al., 2009). Sev-
eral studies have reported a significant effect of obesity
on all-cause mortality in patients with severe COPD, with
mortality being lowest in obese patients (Jee et al., 2006;
Hallin et al., 2007; McGhan et al., 2007; Ora et al., 2009;
Lainscak et al., 2011). Most of these studies have been
carried out in a community-based setting.
By contrast, weight loss, a low body mass index (BMI)
and cachexia have important negative prognostic implica-
tions in patients with COPD (Landbo et al., 1999; Chail-
leux et al., 2003). The role of low BMI in these patients
could have been related to several factors, such as respira-
tory muscle weakness, impaired gas exchange and an
impaired immune response (Landbo et al., 1999).
The present study aimed to assess the association of
obesity and malnutrition with the mortality of hospita-
lised patients with acute exacerbation of COPD and the
risk of readmission in <30 days for the same process.
Materials and methods
The present study included all patients who were admit-
ted to all acute care hospitals of the Spanish Public
Health Service through an emergency department
between 1 January 2006 and 31 December 2007 with
COPD as the primary reason for discharge. All elective
admissions and elective transfers were excluded. Hospital
discharge data were obtained from the Basic Minimum
Data Set (BMDS). BMDS contains sociodemographic and
clinical data for each documented hospital stay, including
sex and age, primary and secondary diagnoses [according
to the International Classification of Diseases, Ninth Revi-
sion, Clinical Modification (ICD-9-CM) code]; primary
and secondary procedures; admission and discharge sta-
tus; length of stay; and hospital characteristics (group 1:
<150 beds; group 2: 150–200 beds, group 3: 200–500
beds; group 4: 500–1000 beds; group 5: >1000 beds). For
every patient, a diagnosis-related group (DRG) was iden-
tified. DRGs are a method of classifying patient hospitali-
sations by diagnosis and procedure on the assumption
that similar costs are expended on patients by using simi-
lar resources. The CMBD registry is compulsory for every
patient admitted to a hospital of the Spanish National
Health Service, a system that cares for >90% of the coun-
try’s population.
Cases were selected if they were discharged with the
diagnosis of COPD (code DRG 88: Chronic Obstructive
Pulmonary Disease; 540: Respiratory infections & inflam-
mations with major complications; or 541: Respiratory
disorders except infections, bronchitis, asthma with major
complications; DRG-AP.21 version). The primary diagno-
sis of COPD was identified using ICD-9-MC codes in the
primary diagnosis field: 491.0, 491.1, 491.9, 491.20,
491.21, 491.22, 496, 518.8, 518.81 and 518.9.
The standardised definition of the variable readmission
in the Spanish CMBD has been defined as a new hospital-
isation in the following month with the same major diag-
nostic category in the main diagnosis.
The patients who had a secondary diagnosis of obesity
(ICD-9-CM: 278.00–278.02) or malnutrition (ICD-9-CM:
260–263.9) were analysed.
The age adjusted Charlson Co-morbidity Index (CCI)
was computed for each patient. This index reflects the
number and importance of comorbid diseases, relieson
ICD-9-CM categories, and was used to adequately adjust
for severity of illness (Charlson et al., 1987; Deyo et al.,
1992).
The following risk factors were identified using ICD-9-
MC codes in any primary or secondary diagnosis field:
cardiac disease: ICD-9-MC: 398.91, 404*, 402.11,
402.91,428–428.9; dementia: ICD-9-MC: 290–290.9; cancer
ICD-9-MC: 140.0–172.9, 174.0–195.8, 200–208.9, V10.0–
V10.9; diabetes: ICD-9-CM: 250.00–250.99; chronic renal
failure: ICD-9-CM: 585–586.99, 582.0–582.9, 583.0–583.7,
588.0–588.9; hypertension: ICD-9-CM: 401.0, 401.1, 401.9;
anaemia: ICD-9-CM: 280.00–285.99; tobacco: ICD-9-CM:
305.10; atrial fibrillation: ICD-9-CM: 427.3–427.32. The
following acute medical illness were considered when they
occurred during the index hospitalisation, and then only
primary diagnoses ICD-9-MC codes were used: acute con-
gestive heart failure: ICD-9-MC: 398.91, 404*, 402.11,
402.91,428–428.9; acute renal failure: ICD-9-MC: 403.11,
403.91,404.12, 585–586; acute respiratory failure: ICD-9-
MC: 518.81–518.84; acute infectious disease: ICD-9-MC:
001–137, 460–466, 487–487.8; and cerebrovascular disease:
ICD-9-MC: 430–438.
The present study was approved by the Ethics Commit-
tee in Infanta Cristina Hospital, Parla, Madrid, Spain.
Statistical analysis
A descriptive analysis of these patients was carried out,
and the demographic variables among the patients diag-
nosed with or without malnutrition, and with or without
obesity, were compared. We used the chi-squared test for
2 ª 2013 The British Dietetic Association Ltd.
Malnutrition and obesity in COPD A. Zapatero et al.
categorical variables with Yates correction, Fisher’s exact
test for dichotomous variables when the expected value of
a cell was <5, and Student’s t-test or analysis of variance
for quantitative variables. All univariate analyses were car-
ried out after adjusting for age and sex. Odds ratios (OR)
and 95% confidence intervals (CI) were estimated from
the regression coefficients.
Because this is an administrative database, the control
of the confounding variables is basic. For this reason, a
multivariate logistic regression analysis was carried out
with the aim of determining the excess of mortality
attributable to malnutrition or obesity, after correction
of possible confounding variables such as the age of the
patient (in years, as a continuous variable), Charlson
index (in points, as a continuous variable), sex and all
variables that had demonstrated a statistically significant
relation in the univariate analysis with mortality [length
of stay (days, continuous variable), cancer, dementia,
heart failure, acute respiratory failure and smoking]. We
also used multivariable logistic regression analysis to
measure the independent association of the following
factors with early readmission to hospital: sex, length of
stay, age, cancer, dementia, heart failure, acute respira-
tory failure, smoking, obesity and malnutrition. A logis-
tic regression analysis with backward stepwise procedure
and P > 0.10 as the criterion for exclusion, was used to
find the best predictive models. Stratified analyses were
performed to examine confounders and interactions
where appropriate. All statistical analyses were carried
out using SPSS, version 16 (SPSS Inc., Chicago, IL, USA).
Results
During the study period, there were 313 233 patient dis-
charges with acute exacerbation of COPD. The median
(SD) age of patients was 73.92 (12.97) years; 70.3% of
the patients were men. The median (SD) stay was
10.75 (9.18) days. A CCI � 2 was present in 22.8% of
the cases. A total of 22 582 (7.2%) subjects were obese,
and 6354 (2%) were diagnosed with some form of mal-
nutrition. The main characteristics of our subjects are
shown in Table 1.
Obese patients were more frequently women (40.8%
versus 29.4%; P < 0.001), younger (70.3 versus 72.8 years;
P < 0.001) and there was a greater proportion of smokers
(17.8% versus 14.0%; P < 0.001) than in non-obese
patients. On the other hand, malnourished patients were
older (75.3 versus 72.8%; P < 0.001), fewer were smokers
(12.1% versus 14%; P < 0.0001) than normoweight
patients, and they were more frequently women (36.5%
versus 29.4%; P < 0.001).
Co-morbid conditions were common in our cohort,
with hypertension, heart failure, diabetes, cancer and
dementia in 31.4%, 17.3% 22.8%, 12.3% and 5.6% of the
overall cohort, respectively. Cancer and dementia was
more prevalent among patients with malnutrition, with
unadjusted ORs in the presence of malnutrition compared
to its absence for cancer (OR = 1.13; 95% CI = 1.05–
1.21), for dementia (OR = 3.68; 95% CI = 3.47–3.94). On
the other hand, these conditions were less prevalent
among patients with obesity (cancer: OR = 0.37; 95%
CI = 0.35–0.39; dementia: OR = 0.35; 95% CI = 0.32–
0.38) compared to its absence. Obese patients more
frequently suffer hypertension, diabetes and acute respira-
tory failure than non-obese or malnourished patients
(Table 1).
Of the 313 233 patients, 37 718 died during admission
(12%) and 52 428 (16.7%) were readmitted at least once
within 30 days of the index date of admission with the
same Major Diagnostic Category as the main diagnosis.
Malnutrition was related to risk for death (unadjusted
OR = 2.15; 95% CI = 2.02–2.29) and readmission (unad-
justed OR = 1.41; 95% CI = 1.32–1.50), whereas obesity
behaved as a protector factor for both (unadjusted OR
for death = 0.41; 95% CI = 0.38–0.44) and unadjusted
OR for readmission = 0.81; 95% CI = 0.77–0.84)
(Table 2).
The lowest risk of readmission and mortality was
linked to a diagnosis of obesity. The association between
obesity in COPD patients and readmission (OR = 0.87;
95% CI = 0.84–0.91) remained significant after adjusting
for possible confounders such as cancer, heart failure,
age, length of stay, sex, smoking or acute respiratory fail-
ure. Obese patients had a 51% reduction in the risk of
mortality (OR = 0.49; 95% = CI 0.46–0.53) after adjust-
ing for possible confounders (Tables 3 and 4).
Compared to normal weight, the risk of readmission
within 30 days in COPD patients is 29% higher if malnu-
trition is documented in medical chart (OR = 1.29; 95%
CI = 1.21–1.37), and the risk of death is 77% higher,
after adjusting for other variables that were significantly
related to mortality in the univariate analyses (OR = 1.77;
95% CI = 1.65–1.89) (Tables 3 and 4).
Discussion
The present study describes the clinical outcomes of a
large cohort of patients after hospitalisation for a severe
exacerbation of COPD. We found that approximately 7%
of patients hospitalised for COPD had a diagnosis in their
clinical chart of obesity and 2% had a diagnosis of mal-
nutrition. Compared to normal weight patients, the risk
of readmission within 30 days after discharge in patients
with a diagnosis of COPD is 13% lower if obese and 29%
higher if malnutrition is documented in their medical
chart. We also have observed that obese patients with
ª 2013 The British Dietetic Association Ltd. 3
A. Zapatero et al. Malnutrition and obesity in COPD
COPD have an almost 50% lower risk of death during
hospitalisation than patients with normal weight and also
that malnutrition is an important predictor of a poor
outcome, with a 77% in-hospital mortality increase.
Landbo et al. (1999) , were the first to examine the
relation between BMI and mortality in patients with
COPD. Their study, based on a large, nonselected, pro-
spectively examined population with a long follow-up,
demonstrated that BMI had an independent effect on all-
causes of mortality both in men and women with severe
COPD, with the lowest risk occurring in normal weight
to overweight subjects and thatmortality decreased with
increasing BMI (Landbo et al., 1999) Lainscak et al.
(2011) analysed the association between BMI and mor-
tality in COPD in a retrospective survey including
patients hospitalised for acute exacerbation of COPD and
found that the optimal BMI with the lowest risk of death
was in the overweight category (BMI of 25.09–
26.56 kg m–2). In another study conducted in European
Nordic countries in hospitalised patients with COPD,
Hallin et al. (2007) found that the lowest mortality was
among overweight patients, whereas being underweight
was related to an increase in overall mortality. The associ-
ation between being underweight and mortality in COPD
Table 1 Characteristics of the patients in the study cohort
Normal-weight (n = 284 297) Obese (n = 22 582) Malnutrition (n = 6354) P
Age (years), mean (SD) 72.8 (15.9) 70.3 (11.9) 75.3 (17.4) <0.0001
Sex (men), mean (SD) 200 841 (70.6) 13 336 (59.2) 4036 (63.5) <0.001
Length of stay (days), mean (range) 9.7 (0–443) 9.6 (0–368) 15.9 (0–300) <0.001
Death, n (%) 35 009 (12.3) 1292 (5.7) 1417 (22.2) <0.001
Readmission, n (%) 47 840 (16.8) 3191 (14.1) 1397 (22.0) <0.001
Tobacco, n (%) 39 822 (14.0) 4025 (17.8) 772 (12.1) <0.001
Diabetes, n (%) 61 581 (21.7) 8703 (38.5) 1126 (17.7) <0.001
Hypertension, n (%) 87 008 (30.6) 9849 (43.6) 1360 (21.4) <0.001
Heart failure, n (%) 47 399 (16.7) 5951 (26.4) 917 (14.4) <0.001
Acute respiratory failure, n (%) 148 779 (52.3) 13 531 (59.9) 3328 (52.4)* <0.001
Cancer, n (%) 36 433 (12.8) 1194 (5.3) 845 (13.3)* <0.001
Dementia, n (%) 16 093 (5.7) 436 (1.2) 1158 (18.2) <0.001
*P = not significant when malnutrition/normal weight is compared.
Table 2 Unadjusted analysis: association between mortality and
readmission with obesity and malnutrition in chronic obstructive
pulmonary disease patients
Odds ratio (95% confidence interval)
Obese patients
Mortality 0.41 (0.38–0.44)
Readmission 0.81 (0.77–0.84)
Malnourished patients
Mortality 2.15 (2.02–2.29)
Readmission 1.41 (1.32–1.50)
Patients were considered for inclusion in the obesity and malnutrition
group if they have a diagnosis included in the hospital discharge report.
Table 3 Risk factors for mortality during admission in the chronic
obstructive pulmonary disease cohort (multivariate regression analysis)
Odds
ratio
95% confidence
interval P
Sex (male) 1.211 1.182 1.242 <0.001
Length of stay (days) 1.004 1.003 1.005 <0.001
Age (years) 1.030 1.029 1.031 <0.001
Cancer 4.641 4.487 4.800 <0.001
Dementia 2.347 2.259 2.440 <0.001
Heart failure 1.184 1.148 1.221 <0.001
Acute respiratory failure 2.248 2.194 2.303 <0.001
Charlson index 1.024 1.015 1.033 <0.001
Tobacco 0.696 0.667 0.727 <0.001
Obesity 0.494 0.465 0.525 <0.001
Malnutrition 1.767 1.651 1.890 <0.001
Table 4 Risk factors for 30-day readmission in the chronic
obstructive pulmonary disease cohort (multivariate regression
analysis)
Odds
ratio
95% confidence
interval P
Sex (male) 0.752 0.729 0.774 <0.0001
Length of stay (days) 1.013 1.011 1.022 <0.0001
Age (years) 1.001 1.000 1.001 0.010
Cancer 1.538 1.486 1.580 <0.0001
Dementia 1.010 0.960 1.051 0.761
Heart failure 1.082 1.055 1.119 <0.0001
Acute respiratory
failure
0.997 0.978 1.016 0.222
Charlson index 1.204 1.176 1.232 <0.0001
Tobacco 0.792 0.778 0.827 <0.0001
Obesity 0.870 0.846 0.915 <0.0001
Malnutrition 1.290 1.218 1.376 <0.0001
4 ª 2013 The British Dietetic Association Ltd.
Malnutrition and obesity in COPD A. Zapatero et al.
patients remained significant after adjusting for possible
confounders such as forced expiratory volume in the first
second (FEV1).
For COPD, several scoring systems for predicting prog-
nosis have been developed. The BODE composite score is
the most frequently used in everyday practice. Although it
is primarily limited to patients with clinically stable disease
as seen in an outpatient setting, this score includes body
mass index, the degree of airflow obstruction, dyspnea and
exercise capacity (E; Celli et al., 2004). The authors found
that BMI values <21 were associated with an increased risk
of death, which is an observation similar to that reported
by Landbo et al. (1999) in a large population study.
The mechanisms underlying the above-mentioned find-
ings on the obesity paradox remain unresolved. Why does
obesity paradoxically improve survival in patients with
COPD and why is a higher BMI associated with fewer
respiratory-related deaths? Ora et al. (2009) recently
explored the relationship between obesity, operating lung
volumes and exercise intolerance in patients with moder-
ate to severe COPD. By contrast to current beliefs, the
combination of obesity and COPD was not associated
with diminished exercise capacity or greater dyspnea
compared to normal weight patients with a similar reduc-
tion in FEV1. The explanation could be that the presence
of airway obstruction does not alter the relationship
between increasing BMI and lung volumes (expiratory
reserve volume and functional residual capacity) seen in
healthy populations (Deesomchok et al., 2010). In other
words, these lung volume components also decrease
exponentially as BMI increases in patients with COPD.
Obese COPD patients consistently demonstrate less lung
hyperinflation and have a larger inspiratory capacity and
inspiratory capacity/total lung capacity ratio than their
lean counterparts matched for FEV1 (Ora et al., 2009).
Guenette et al.(2010) concludes that a fundamental
question is whether the reported benefits of an increased
BMI in this population are derived from an increased fat-
free skeletal muscle mass, from the effects of excessive
adipose tissue on the mechanics of the respiratory system,
or from some combination of both. The contribution of
abdominal fat mass to systemic inflammation often pres-
ent in COPD has been demonstrated in different studies,
although the precise mechanism and significance of the
associations between adipokines and lung disease at the
current moment is confusing, and needs further investiga-
tion (Breyer et al., 2009; Rutten et al., 2010; Sood, 2010).
Prospective longitudinal studies that examine the interac-
tion of changes in body composition and the temporal
progression of pulmonary function decline (after control-
ling for the relevant comorbidities) are needed to better
understand this intriguing relationship between increased
BMI and survival in COPD populations.
Malnutrition is a well known complication of COPD
(Chailleux et al., 2003). It is clear that being underweight
or having a low fat-free mass is associated with poor sur-
vival in COPD (Celli et al., 2004; Tsimogianni et al.,
2009) independently of the degree of airway obstruction
(Landbo et al., 1999), even in patients receiving long-
term oxygen therapy (Chailleux et al., 2003; Marti et al.,
2006). Furthermore, a decrease in fat mass has recently
been identified as an independent risk factor for mortality
in COPD patients, regardless of the fat mass (Schols
et al., 2005). Hence, protein depletion may be a negative
feature in the prognosis of these patients, even though
their weight is normal (Marti et al., 2006).
Nutritional assessment should be included in the initial
evaluation of all patients and the diagnosis of malnutri-
tion/undernourishment in discharge reports (Landbo
et al., 1999; Hallin et al., 2007; Lainscak et al., 2011);
however, malnutrition is systematically underdiagnosed,
and therefore a long way from being corrected. The work
of nurses or dietitians is important in this field and could
represent an invaluable tool for improving the quality of
care given to the patients admitted to our departments.It
is also necessary for foodservices to be recognised as a
clinical and not corporate or ‘hotel’ activity. Hospital
information systems constitute fundamental tools for
clinical management (Marco et al., 2011) but, on many
occasions, the diagnosis of malnutrition is not reflected
in discharge sheets.
Whether rectifying nutritional status with directed
efforts at nutritional support or whether malnutrition
would resolve with more intensive COPD care remains
unclear (Ferreira et al., 2005). However, given the means
available to correct malnutrition, prospective interven-
tional studies (such as evaluating the effects of different
COPD therapies on nutritional parameters or improving
nutrition in these patients) are warranted.
Some potential limitations of the present study deserve
comment, particularly when using administrative data. A
large proportion of patients hospitalised with the diagno-
sis of COPD have never had a confirmatory test, includ-
ing those with presumably advanced disease. Compared
to patients with chronic heart failure, patients with
COPD are less likely to have had the confirmatory test
performed, even when both conditions coexist (Damarla
et al., 2006). In the present study we do not have the
BMI stage and, similarly, we know that both the diagnosis
of obesity and malnutrition may be underdiagnosed
(Marco et al., 2011). On the other hand, we have been
able to provide a very large series of patients (>300 000)
comprising all COPD patients admitted to the internal
medicine departments of Spanish hospitals for a consecu-
tive period of 2 years with all its associated statistical
power.
ª 2013 The British Dietetic Association Ltd. 5
A. Zapatero et al. Malnutrition and obesity in COPD
On the basis of the present study of subjects with COPD,
utilising a unique database from an integrated health care
system, we conclude that obesity appears to be associated
with an important reduction in mortality during admis-
sions for acute exacerbations of COPD and a reduction in
the risk of readmission. Similarly, malnutrition could be an
important independent factor for mortality and rehospital-
isation in the next 30 days. Further studies are needed to
show whether identifying and treating weight loss could act
towards improving the prognosis for hospitalised COPD
patients. Additionally the obesity paradox is a complex
phenomenon that requires additional investigation, and
future studies should consider weight change when evaluat-
ing the longitudinal association among health, overweight/
obesity and outcomes.
Acknowledgments
The authors thank the Spanish Minister of Health for the
permission to obtain of the data.
Conflicts of interest, sources of funding and
authorship
The authors declare that there are no conflicts of interest.
No funding was received for the conduct and interpreta-
tion of these analyses.
RB conceived the study, performed the statistical analy-
sis and analysed the results. AZ was the coordinator of
the group and, as president of the Group of Medical
Management of the SEMI (Sociedad Espa~nola de Medi-
cina Interna–Spanish Society of Internal Medicine),
acted as the official liaison with the Spanish Ministry of
Health for the procurement of the crude data. JR car-
ried out the bibliographic revision. JM wrote the first
draft of the paper, as well as its final version, for the
approval of the other authors. SP helped to obtain
meaning from the raw data. JEL performed all the perti-
nent crosses between the partial results to achieve the
statistically significant final results. JC helped to write
the discussion of the paper and carried out the biblio-
graphic revision.
All authors contributed to the design and conduct of
the study and read and approved the final manuscript
submitted for publication.
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