Yawn Barbara P, Wollan Peter C, Bertram Susan L, Lowe David, Butterfield Joseph H, Bonde Denise, Li James T C
Department of Research, Olmsted Medical Center, 210 Ninth St SE, Rochester, MN 55904, USA.
Mayo Clin Proc. 2007 Apr;82(4):414-21. doi: 10.4065/82.4.414.
To assess the frequency and types of visits related to modifications in the intensity of asthma medications.
We retrospectively reviewed the medical records of adults (aged 18-40 years) and children (aged 6-17 years) living in Olmsted County, Minnesota, to evaluate changes in asthma medications by dose and drug class and site and type of visit (routine vs unscheduled) at the time of changes. All records from all visits were reviewed for each patient to identify asthma-related visits at all sites of care from January 1, 2002, through December 31, 2003.
The study consisted of 397 adults and children. In 255 patients, 597 asthma medication changes occurred. Step-up changes usually occurred because of an exacerbation or loss of control of asthma and adhered to the medication hierarchy in the national asthma guidelines. Twenty step-up changes involved skipping inhaled corticosteroid (ICS) monotherapy and moving directly to combined ICSs plus a long-acting beta-agonist (LABA). Lack of documentation of asthma symptom frequency or interference with activities made it impossible to determine whether these 'skips' were appropriate. Only 78 physician-directed step-down changes were documented, usually to a lower dose of combined ICSs and LABAs or a move from combined ICSs and LABAs to anti-inflammatory monotherapy. Patients initiated additional step-down changes between encounters. Step-down changes occurred at routine or follow-up asthma visits, but the limited number of such visits provided few opportunities for step-down care.
The continuing episodic-style treatment of asthma aimed at exacerbation management facilitates step-up changes in asthma therapy. The dearth of asthma evaluation visits limited opportunities to step down use of asthma medications and to provide long-term asthma management.
评估与哮喘药物剂量调整相关的就诊频率及类型。
我们回顾性分析了明尼苏达州奥姆斯特德县18至40岁成年人及6至17岁儿童的病历，以评估哮喘药物在剂量、药物类别方面的变化，以及剂量调整时的就诊地点和类型（常规就诊与非预约就诊）。对每位患者的所有就诊记录进行审查，以确定2002年1月1日至2003年12月31日期间在所有医疗机构与哮喘相关的就诊情况。
该研究纳入397名成年人及儿童。255名患者共发生597次哮喘药物调整。升级调整通常因哮喘加重或控制不佳而发生，并遵循国家哮喘指南中的药物分级。20次升级调整跳过了吸入性糖皮质激素（ICS）单药治疗，直接采用ICS联合长效β受体激动剂（LABA）治疗。由于缺乏哮喘症状频率记录或对活动的影响记录，无法确定这些“跳过”是否恰当。仅记录了78次由医生指导的降级调整，通常是降低ICS联合LABA的剂量，或从ICS联合LABA转为抗炎单药治疗。患者在两次就诊之间自行进行了更多的降级调整。降级调整发生在常规或随访哮喘就诊时，但此类就诊次数有限，提供的降级治疗机会很少。
针对哮喘加重进行的持续性间歇性治疗有助于哮喘治疗的升级调整。哮喘评估就诊的缺乏限制了降低哮喘药物使用剂量及提供长期哮喘管理的机会。
