***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE This study attempted to determine the total direct costs derived from the management of chronic bronchitis and COPD in an ambulatory setting through a prospect i ve , 1-year , follow-up study . METHOD A total of 1,510 patients with chronic bronchitis and COPD were recruited from 268 general practice s located throughout Spain . Patients were followed up for 1 year . All direct medical costs incurred by the cohort and related to their respiratory disease were quantified . Costs were calculated for patients with confirmed COPD according to the degree of severity of airflow obstruction . RESULTS The global mean direct yearly cost of chronic bronchitis and COPD was $ 1,876 . The cost generated by patients with COPD was $ 1,760 , but the cost of severe COPD ( $ 2,911 ) was almost double that of mild COPD ( $ 1,484 ) . Hospitalization costs represented 43.8 % of costs , drug acquisition costs were 40.8 % , and clinic visits and diagnostic tests represented only 15.4 % of costs . CONCLUSION This is the first prospect i ve follow-up study on a large cohort of patients with chronic bronchitis and COPD aim ed at quantifying direct medical costs under usual clinical practice in the community . Costs of chronic bronchitis and COPD were almost twofold those reported for asthma . Patterns of COPD management in the community differ from those recommended in guidelines . COPD represents a great health-care burden in developed countries , and aging of the population and continuing smoking habits predict that it will continue to do so in the future To date , no international surveys estimating the burden of chronic obstructive pulmonary disease ( COPD ) in the general population have been published . The Confronting COPD International Survey aim ed to quantify morbidity and burden in COPD subjects in 2000 . From a total of 201,921 households screened by r and om-digit dialling in the USA , Canada , France , Italy , Germany , the Netherl and s , Spain and the UK , 3,265 subjects with a diagnosis of COPD , chronic bronchitis or emphysema , or with symptoms of chronic bronchitis , were identified . The mean age of the subjects was 63.3 yrs and 44.2 % were female . Subjects with COPD in North America and Europe appear to underestimate their morbidity , as shown by the high proportion of subjects with limitations to their basic daily life activities , frequent work loss ( 45.3 % of COPD subjects of < 65 yrs reported work loss in the past year ) and frequent use of health services ( 13.8 % of subjects required emergency care in the last year ) , and may be undertreated . There was a significant disparity between subjects ' perception of disease severity and the degree of severity indicated by an objective breathlessness scale . Of those with the most severe breathlessness ( too breathless to leave the house ) , 35.8 % described their condition as mild or moderate , as did 60.3 % of those with the next most severe degree of breathlessness ( breathless after walking a few minutes on level ground ) . This international survey confirmed the great burden to society and high individual morbidity associated with chronic obstructive pulmonary disease in subjects in North America and Europe Exacerbations of chronic obstructive pulmonary disease ( COPD ) are associated with worse health and increased healthcare utilisation . The Inhaled Steroids in Obstructive Lung Disease in Europe ( ISOLDE ) study in COPD showed a 26 % reduction in the yearly rate of exacerbations in patients treated with fluticasone propionate ( FP ) compared to placebo , but did not indicate which patients showed greatest benefit . In this study the patients were stratified into mild and moderate‐to‐severe COPD using the American Thoracic Society criterion of forced expiratory volume in one second ( FEV1 ) 50 % predicted , and the total number of exacerbations and those requiring treatment with oral corticosteroids were examined . There were 391 ( 195 FP ) patients with mild COPD and 359 ( 180 FP ) patients with moderate‐to‐severe disease .  The exacerbation rate was highly skewed in mild disease , but more normally distributed in moderate‐to‐severe disease . FP reduced the overall exacerbation rate in moderate‐to‐severe disease ( FP median rate 1.47 yr−1 , placebo 1.75 yr−1 ) , but not in mild disease ( FP 0.67 yr−1 , placebo 0.92 yr−1 ) . FP use was associated with fewer patients with ≥1 exacerbation·yr−1 being treated with oral corticosteroids ( mild : FP 8 % , placebo 16 % ; moderate‐to‐severe : FP 17 % , placebo 30 % ) . Effects  of fluticasone propionate  on exacerbations were seen predominantly in patients with a postbronchodilator forced expiratory volume in one second < 50 % predicted . These data support recommendations in the Global Initiative for Chronic Obstructive Disease treatment guidelines that inhaled corticosteroids should be considered in patients with moderate‐to‐severe chronic obstructive pulmonary disease who experience recurrent exacerbations OBJECTIVES To ascertain the prevalence , diagnostic level , and treatment of COPD in Spain through a multicenter study comprising seven different geographic areas . DESIGN AND PARTICIPANTS This is an epidemiologic , multicenter , population -based study conducted in seven areas of Spain . A total of 4,035 men and women ( age range , 40 to 69 years ) who were r and omly selected from a target population of 236,412 subjects participated in the study . INTERVENTIONS Eligible subjects answered the European Commission for Steel and Coal question naire . Spirometry was performed , followed by a bronchodilator test when bronchial obstruction was present . RESULTS The prevalence of COPD was 9.1 % ( 95 % confidence interval [ CI ] , 8.1 to 10.2 % ) , 15 % in smokers ( 95 % CI , 12.8 to 17.1 % ) , 12.8 % in ex-smokers ( 95 % CI , 10.7 to 14.8 % ) , and 4.1 % in nonsmokers ( 95 % CI , 3.3 to 5.1 % ) . The prevalence in men was 14.3 % ( 95 % CI , 12.8 to 15 . 9 % ) and 3.9 % in women ( 95 % CI , 3.1 to 4.8 % ) . Marked differences were observed between sexes in smoking ; the percentage of nonsmokers was 23 % in men and 76.3 % in women ( p<0.0001 ) . The prevalence of COPD varied among the areas , ranging from 4.9 % ( 95 % CI , 3.2 to 7.0 % ) in the area of the lowest prevalence to 18 % ( 95 % CI , 14.8 to 21.2 % ) in the area of the highest . There was no previous diagnosis of COPD in 78.2 % of cases ( 284 of 363 ) . Only 49.3 % of patients with severe COPD , 11.8 % of patients with moderate COPD , and 10 % of patients with mild COPD were receiving some kind of treatment for COPD . Multivariate analysis showed that individuals had a higher probability of having received a previous diagnosis of COPD if they lived in urban areas , were of male gender , were > 60 years old , had higher educational levels , had > 15 pack-year smoking history , or had symptoms of chronic bronchitis . CONCLUSIONS COPD is a very frequent disease in Spain , and presents significant geographic variations and a very low level of previous diagnosis and treatment , even in the most advanced cases BACKGROUND Inhaled long-acting beta2 agonists improve lung function and health status in symptomatic chronic obstructive pulmonary disease ( COPD ) , whereas inhaled corticosteroids reduce the frequency of acute episodes of symptom exacerbation and delay deterioration in health status . We postulated that a combination of these treatments would be better than each component used alone . METHODS 1465 patients with COPD were recruited from outpatient departments in 25 countries . They were treated in a r and omised , double-blind , parallel-group , placebo-controlled study with either 50 microg salmeterol twice daily ( n=372 ) , 500 microg fluticasone twice daily ( n=374 ) , 50 microg salmeterol and 500 microg fluticasone twice daily ( n=358 ) , or placebo ( n=361 ) for 12 months . The primary outcome was the pretreatment forced expiratory volume in 1s ( FEV1 ) after 12 months treatment ' and after patients had abstained from all bronchodilators for at least 6h and from study medication for at least 12h . Secondary outcomes were other lung function measurements , symptoms and rescue treatment use , the number of exacerbations , patient withdrawals , and disease-specific health status . We assessed adverse events , serum cortisol concentrations , skin bruising , and electrocardiograms . Analysis was as predefined in the study protocol . FINDINGS All active treatments improved lung function , symptoms , and health status and reduced use of rescue medication and frequency of exacerbations . Combination therapy improved pretreatment FEV1 significantly more than did placebo ( treatment difference 133 mL , 95 % CI 105 - 161 , p<0.0001 ) , salmeterol ( 73 mL , 46 - 101 , p<0.0001 ) , or fluticasone alone ( 95 mL , 67 - 122 , p<0.0001 ) . Combination treatment produced a clinical ly significant improvement in health status and the greatest reduction in daily symptoms . All treatments were well tolerated with no difference in the frequency of adverse events , bruising , or clinical ly significant falls in serum cortisol concentration . INTERPRETATION Because inhaled long-acting beta2 agonists and corticosteroid combination treatment produces better control of symptoms and lung function , with no greater risk of side-effects than that with use of either component alone , this combination treatment should be considered for patients with COPD The main purpose of this study was to assess whether pharmacological treatments prescribed by respiratory physicians to patients with chronic obstructive pulmonary disease ( COPD ) were consistent with the guidelines . The treatments prescribed by respiratory physicians to 631 consecutive patients with COPD , compared to 879 asthmatics were prospect ively recorded . All subjects underwent peak expiratory flow rate measurement , spirometry and assessment of recent evolution and dyspnoea ( visual analogue and Medical Research Council scales ) . Patients with COPD received more treatments than asthmatics ( mean±sd : 2.6±0.5 versus 2.2±0.4 , p<0.0001 ) . Treatments administered to patients with COPD were  β2-agonists  in 78 % ( versus 94 % in asthmatics ) ,  anticholinergic agents ( AC ) in 56 % ( versus 16 % in asthma ) ,  methylxanthines  in 31 % ( versus 15 % in asthma ) and  inhaled corticosteroids  in 76 % ( versus 85 % in asthma ) . Intensity of treatment was influenced by disease severity for all treatments except AC . In conclusion , pharmacological treatment of chronic obstructive pulmonary disease by respiratory physicians is only partially consistent with current guidelines , with a high proportion of inhaled corticosteroid prescriptions and a relative under-use of anticholinergic agents ; this most likely reflects the persistent uncertainties of physicians , and emphasizes that more efforts are required to improve implementation of chronic obstructive pulmonary disease guidelines and assess the efficacy and cost-effectiveness of recommended strategies BACKGROUND This study estimated the healthcare re source utilisation and costs of chronic obstructive pulmonary disease ( COPD ) patients , staged by severity , in the Italian pneumology departments ( PDs ) . METHODS The project was a multi-centre observational study conducted in 11 Italian PDs throughout the country . A total of 268 patients were recruited and followed prospect ively for 1 year . For the purpose of analysis , patients were divided into four groups according to the severity at onset : mild COPD ( stage I)-postbronchodilator FEV1/FVC < 70 % and FEV1 > or=80 % of predicted ; moderate COPD ( stage II)-postbronchodilator FEV1/FVC < 70 % and 50 % < or = FEV1 < 80 % of predicted ; severe COPD ( stage III)-postbronchodilator FEV1/FVC < 70 % and 30 % < or = FEV1 < 50 % of predicted ; very severe COPD ( stage IV)-postbronchodilator FEV1/FVC < 70 % and FEV1 < 30 % of predicted , or clinical signs of either respiratory or cardiac failure . RESULTS Subgroups differed significantly in the main demographic and clinical variables . Broadly , higher severity was associated with older age , longer disease duration , and more frequent exacerbations . Patients with severe COPD used more re sources for almost all services than those with mild and moderate forms . The annual average cost per patient was 3040.2 euros ( 1046.7 euros for mild , 2319.0 euros for 
    Output:
    
Treatment of COPD allows for the identification of areas of inefficiency .