COPD指南的应用不足

亚特兰大——在美国胸内科医师协会(ACCP)年会上报告的一项观察性研究的结果提示，无论疾病严重程度如何，患有稳定慢性阻塞性肺病并在门诊接受治疗的所有患者中，接近一半未被提供符合指南的治疗。这项研究还提示，当患者接受呼吸内科医生和基层医生共同管理时，获得符合指南的治疗的可能性更大。

加尔维斯顿德州大学医学院Gulshan Sharma博士指出，对于门诊COPD患者的治疗临床实践指南已发布并定期进行更新。之前有研究显示这些指南对于提高COPD患者的治疗质量和减少病情恶化及住院具有很大价值。但这些指南在临床实践中的应用程度尚不清楚。

这项研究中纳入临床诊断为COPD并在2010年1 ~12月间至少有1次门诊就诊的成人患者。受试者的平均年龄为67岁，其中46%为女性，20%无合并疾病，75%有1~2种合并疾病。大约7%为GOLDⅠ期疾病，接近一半(超过46%)为GOLDⅡ期疾病，33%为Ⅲ期疾病，13%为Ⅳ期疾病。并且，47%的患者单纯接受基层医生的管理，41%接受基层医生和呼吸内科医生共同管理，10%未接受基层医生管理而主要接受专科医生的诊治，大约2%无较为固定的医疗服务提供者。

结果显示，在这450例患者中，56%接受了符合2010年全球慢性阻塞性肺病行动(GOLD)的特定分期建议。不同治疗水平患者的年龄、性别、种族、疾病严重程度或多变量分析中的合并疾病均未见差异，但与单纯接受基层医生治疗的患者相比，接受基层医生和呼吸内科医生共同管理的患者得到适当水平治疗的机会更多(比值比为4.6)。

Sharma博士总结称，这一结果提示，需要提高对临床实践指南的知晓程度以及遵照指南治疗对COPD患者的重要性，尤其是在基层医生管理的患者中。

Sharma博士披露无相关利益冲突。

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By: SHARON WORCESTER, Internal Medicine News Digital Network

ATLANTA – Regardless of disease severity, guideline-concordant treatment is not provided to nearly half of all patients who have stable chronic obstructive pulmonary disease and are treated in the ambulatory care setting, findings from an observational study suggest.

The study also indicated that guideline-concordant treatment was more likely to be provided when patients were comanaged by a pulmonologist and a primary care physician.

Of 450 patients, 56% received guideline-concordant care as outlined by the 2010 Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage-specific recommendations, Dr. Gulshan Sharma reported at the annual meeting of the American College of Chest Physicians.

No differences were found in treatment level with respect to age, gender, race, disease severity, or comorbidities on multivariate analysis, but patients comanaged by a primary care physician and a pulmonologist were more likely to receive an appropriate level of care, as compared to patients treated by a primary care physician (odds ratio, 4.6), said Dr. Sharma of the University of Texas Medical Branch, Galveston.

Clinical practice guidelines for the treatment of patients with COPD in the ambulatory care setting are issued and updated regularly. Previous studies have demonstrated the value of these guidelines for improving the quality of care of patients with COPD and for reducing exacerbations and hospitalizations.

However, the degree to which these guidelines are implemented in clinical practice has been unclear, Dr. Sharma said. The study findings suggest that they are underutilized, particularly by primary care physicians.

Patients included in the study were adults with a clinical diagnosis of COPD and at least one outpatient visit between January and December 2010. The mean age of participants was 67 years, 46% were women, 20% had no comorbidities, and 75% had one or two comorbidities.

About 7% had GOLD stage I disease, almost half (more than 46%) had GOLD stage II disease, 33% had stage III disease, and 13% had stage IV disease.

Additionally, 47% were managed by a primary care physician alone, 41% were comanaged by a primary care physician and a pulmonologist, 10% did not have a primary care physician and received care mainly from a specialist, and about 2% had no regular care provider.

The findings indicate a need for efforts to increase awareness of clinical practice guidelines and the importance of adherence to the guidelines in patients with COPD, particularly among primary care physicians, Dr. Sharma concluded.

Dr. Sharma reported having no disclosures.