Bourbeau J, Sebaldt R J, Day A, Bouchard J, Kaplan A, Hernandez P, Rouleau M, Petrie A, Foster G, Thabane L, Haddon J, Scalera A
Montreal Chest Institute, McGill University Health Center, Montreal, Canada.
Can Respir J. 2008 Jan-Feb;15(1):13-9. doi: 10.1155/2008/173904.
BACKGROUND: The information on usual care for patients with chronic obstructive pulmonary disease (COPD) in primary care is limited in Canada. OBJECTIVE: To evaluate primary care practice in patients with COPD in Quebec and Ontario compared with recommended care. METHODS: The COPD Care Gap Evaluation (CAGE) was a prospective, cross-sectional study. Physicians' self-reported data of enrolled COPD patients were compared with the recommended care for the level of disease severity (using the Canadian Thoracic Society classification by symptoms) and stability, derived from Canadian Thoracic Society COPD guidelines. Pharmacological treatment, spirometric confirmation of diagnosis and nonpharmacological management, including smoking cessation counselling, influenza immunization and referral for pulmonary rehabilitation, were assessed. RESULTS: Participating physicians (n=161; 44 in Quebec, 117 in Ontario) recruited 1090 patients (320 in Quebec, 770 in Ontario). The mean (+/- SD) age of the patients was 69.9+/-10.4 years; 60% were male and 40% were currently smoking. Pharmacological treatment that matched guideline recommendations was identified in 34% of patients. Discrepancies between reported and recommended treatment stemmed from nonprescription of long-acting bronchodilators (LABDs) for patients with moderate (27%) and severe (21%) COPD, nonprescription of two long-acting beta agonists (a beta(2)-agonist and an anticholinergic) for patients with severe COPD (51%), and prescription of inhaled corticosteroids (63%) and LABDs (47%) for patients with mild COPD for which the treatment is not recommended. Spirometric confirmation of diagnosis, as recommended by the guidelines, was reported in 56% of patients. For nonpharmacological management, smoking cessation counselling (95%) and influenza immunization (80%) were near optimal. Referral for pulmonary rehabilitation (9%) was not common. Differences between provinces were seen mainly in the prescription of short-acting bronchodilators (89% in Quebec, 76% in Ontario) and LABDs (60% in Quebec, 80% in Ontario). CONCLUSIONS: Substantial gaps between recommended and current care exist in the management of COPD patients in primary care practice. Undertreatment of patients with severe COPD has potential clinical implications, including loss of autonomy and hospitalization.
背景：在加拿大，关于基层医疗中慢性阻塞性肺疾病（COPD）患者常规护理的信息有限。 目的：评估魁北克省和安大略省COPD患者的基层医疗实践，并与推荐护理进行比较。 方法：COPD护理差距评估（CAGE）是一项前瞻性横断面研究。将登记的COPD患者的医生自我报告数据与根据加拿大胸科学会COPD指南得出的针对疾病严重程度（使用加拿大胸科学会按症状分类）和稳定性的推荐护理进行比较。评估了药物治疗、肺功能测定确诊以及非药物管理，包括戒烟咨询、流感疫苗接种和转介至肺康复治疗。 结果：参与研究的医生（n = 161；魁北克44名，安大略117名）招募了1090名患者（魁北克320名，安大略770名）。患者的平均（±标准差）年龄为69.9±10.4岁；60%为男性，40%目前仍在吸烟。34%的患者接受了符合指南推荐的药物治疗。报告的治疗与推荐治疗之间的差异源于中度（27%）和重度（21%）COPD患者未开具长效支气管扩张剂（LABD）、重度COPD患者未开具两种长效β受体激动剂（一种β₂受体激动剂和一种抗胆碱能药物）（51%），以及为轻度COPD患者开具了不推荐使用的吸入性糖皮质激素（63%）和LABD（47%）。56%的患者报告进行了指南推荐的肺功能测定确诊。对于非药物管理，戒烟咨询（95%）和流感疫苗接种（80%）接近最佳水平。转介至肺康复治疗（9%）并不常见。两省之间的差异主要体现在短效支气管扩张剂的处方上（魁北克89%，安大略76%）以及LABD的处方上（魁北克60%，安大略80%）。 结论：在基层医疗实践中，COPD患者的推荐护理与当前护理之间存在显著差距。重度COPD患者治疗不足具有潜在的临床影响，包括自主性丧失和住院治疗。
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