Background:Chronic obstructive pulmonary disease (COPD) generates a high burden on health care, and hospital admissions represent a substantial proportion of the overall costs of the disease. Integrated care (IC) has shown efficacy to reduce hospitalisations in COPD patients at a pilot level. Deployment strategies for IC services require assessment of effectiveness at the health care system level.Aims:The aim of this study was to explore the effectiveness of a community-based IC service in preventing hospitalisations and emergency department (ED) visits in stable frail COPD patients.Methods:From April to December 2005, 155 frail community-dwelling COPD patients were randomly allocated either to IC (n=76, age 73 (8) years, forced expiratory volume during the first second, FEV1 41(19) % predicted) or usual care (n=84, age 75(9) years, FEV1 44 (20) % predicted) and followed up for 12 months. The IC intervention consisted of the following: (a) patient’s empowerment for self-management; (b) an individualised care plan; (c) access to a call centre; and (d) coordination between the levels of care. Thereafter, hospital admissions, ED visits and mortality were monitored for 6 years.Results:IC enhanced self-management (P=0.02), reduced anxiety–depression (P=0.001) and improved health-related quality of life (P=0.02). IC reduced both ED visits (P=0.02) and mortality (P=0.03) but not hospital admission. No differences between the two groups were seen after 6 years.Conclusion:The intervention improved clinical outcomes including survival and decreased the ED visits, but it did not reduce hospital admissions. The study facilitated the identification of two key requirements for adoption of IC services in the community: appropriate risk stratification of patients, and preparation of the community-based work force.

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Gliadin alleles were identified in 100 common wheat cultivars registered and/or grown in Spain during the last 40 years. A very high level of genetic polymorphism was found: in total, 103 allelic variants including one null‐allele were found at the six major Gli loci in the Spanish wheats studied. An average genetic diversity for these six loci was found to be higher (H=0.844) than in any group of wheat cultivars studied previously. Spanish wheats bred in Spain demonstrated even higher genetic diversity (H=0.868), probably because of the occurrence in this group of some landraces (local varieties) assumed to be strongly differentiated to fit local environments. The high level of genetic diversity of wheats grown in Spain was maintained by the introduction of distantly related wheat germplasm from different sources, especially from Italy and CIMMYT. A slight decrease of genetic diversity in recently registered cultivars might be caused by the excessive introduction of French wheats. Thirteen new alleles found in Spanish wheats were catalogued, including Gli‐D2w which encodes the first Gli‐D2‐controlledγ‐gliadin to be found.

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