Frieri Marianne, Therattil Jaya, Dellavecchia Deborah, Rockitter Susan, Pettit Jeff, Zitt Myron
Department of Medicine, Nassau University Medical Center and State University of New York at Stony Brook, East Meadow 11554, USA. mfrieri:@ncmc.edu
J Asthma. 2002 Aug;39(5):405-12. doi: 10.1081/jas-120004033.
Allergy immunology specialists (AIs) differ from primary care physicians (PCP) in their treatment of asthma. A limited retrospective chart review of several visits over a 1-year period in 1997 evaluating the quality of asthma care by AIs vs. PCPs was conducted in an academic center. Data concerning quality, effectiveness and cost of asthma care was randomly collected from 15 AIs and 15 PCPs from charts at 3-month intervals over a 1-year period. Information obtained from data collection forms revealed that asthma patients evaluated by AIs had more visits and received a greater quantity of medication compared to those treated by PCPs. All 15 patients with persistent asthma followed by AIs were treated with inhaled corticosteroids at each visit in contrast to only 80% of those treated by PCPs. The total numbers of controller medications (i.e., inhaled corticosteroids, salmeterol, cromolyn, and theophylline) that were utilized, as recommended, by the National Asthma Expert Panel (NAEP) of the National Heart, Lung, and Blood Institute (NHLBI) guidelines were 70 by AIs vs. 24 by PCPs over three visits. Cromolyn was prescribed five times over three visits by AIs and not at all by PCPs. Recognition and treatment of coexisting allergic rhinitis was evident in only 13% of patients treated by PCPs as compared to 80% in those treated by AIS. (p < 0.0001). However, all patients treated by AIs were skin tested to explore the presence of allergic triggers, while no patients treated by PCPs were evaluated for IgE-mediated reactions. Treatment cost for allergic rhinitis was therefore higher, at $2039, for AIs as compared to $741 for PCPs. There were no peakflow values in charts obtained from PCPs. However, all charts from AIs had peakflow values, which improved during the course of therapy in 33% of patients. Total medication costs for asthma were higher for AIs @ $5,646.30 vs. $1,932.25 for PCPs. Total medication costs for allergic rhinitis plus asthma were higher for AIs @ $7615 vs. $2681 for PCPs. However, patients treated by AIs had more severe asthma and required more frequent visits. Ipratropium bromide was prescribed a total of four times over several visits by PCPs vs. only once by AIs. In comparing asthma care between AI specialists and PCPs, it was found that AI specialists treat more severe asthmatics, provide more frequent follow-up visits, utilize peak flow rates, prescribe more controller medications, and more often recognize and treat comorbid conditions such as allergic rhinitis that impact on asthma care. Thus, although treatment costs for AIs are higher, these costs are justified by a quality of care that is more consistent with national (NHLBI) guidelines.
过敏免疫专科医生（AIs）在哮喘治疗方面与初级保健医生（PCPs）有所不同。1997年，在一所学术中心对1年内多次就诊情况进行了有限的回顾性图表审查，以评估过敏免疫专科医生与初级保健医生的哮喘护理质量。在1年期间，每隔3个月从15名过敏免疫专科医生和15名初级保健医生的图表中随机收集有关哮喘护理质量、有效性和成本的数据。从数据收集表中获得的信息显示，与初级保健医生治疗的患者相比，由过敏免疫专科医生评估的哮喘患者就诊次数更多，用药量更大。15名接受过敏免疫专科医生持续治疗的哮喘患者每次就诊均接受吸入性糖皮质激素治疗，而初级保健医生治疗的患者中只有80%如此。根据美国国立心肺血液研究所（NHLBI）的国家哮喘专家小组（NAEP）指南建议使用的控制药物（即吸入性糖皮质激素、沙美特罗、色甘酸钠和茶碱）总数，过敏免疫专科医生在三次就诊中为70种，而初级保健医生为24种。色甘酸钠在过敏免疫专科医生的三次就诊中被开了5次，初级保健医生则完全未开。初级保健医生治疗的患者中只有13%的患者对并存的过敏性鼻炎进行了识别和治疗，而过敏免疫专科医生治疗的患者中这一比例为80%。（p < 0.0001）。然而，所有接受过敏免疫专科医生治疗的患者都进行了皮肤测试以探究过敏触发因素的存在，而初级保健医生治疗的患者中没有进行IgE介导反应的评估。因此，过敏免疫专科医生治疗过敏性鼻炎的费用更高，为2039美元，而初级保健医生为741美元。从初级保健医生处获得的图表中没有峰值流速值。然而，所有过敏免疫专科医生的图表都有峰值流速值，其中33%的患者在治疗过程中有所改善。过敏免疫专科医生治疗哮喘的总药物费用更高，为5646.30美元，而初级保健医生为1932.25美元。过敏免疫专科医生治疗过敏性鼻炎加哮喘的总药物费用更高，为7615美元，而初级保健医生为2681美元。然而，接受过敏免疫专科医生治疗的患者哮喘病情更严重，需要更频繁的就诊。初级保健医生在几次就诊中总共开了4次异丙托溴铵，而过敏免疫专科医生只开了1次。在比较过敏免疫专科医生和初级保健医生的哮喘护理时发现，过敏免疫专科医生治疗的哮喘患者病情更严重，提供更频繁的随访，使用峰值流速，开更多的控制药物，并且更经常识别和治疗影响哮喘护理的合并症，如过敏性鼻炎。因此，尽管过敏免疫专科医生的治疗费用更高，但这些费用因与国家（NHLBI）指南更一致的护理质量而合理。
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