Division of Pediatric Pulmonology, Akron Children's Hospital, Akron, Ohio, USA.
Pediatr Pulmonol. 2011 Sep;46(9):870-81. doi: 10.1002/ppul.21442. Epub 2011 Apr 4.
There is no standard definition of a CF pulmonary exacerbation universally accepted by clinicians. We aimed to investigate the variability of clinical practice among US CF clinicians in the diagnosis and treatment of exacerbations. Using clinical vignettes, we examined if variation in the identification and treatment of CF exacerbations is common, if practice patterns differ between CF care centers and what clinical factors determine treatment. Twenty-eight clinical cases were developed by varying five clinical factors. Participants were given four options for treatment of the patient described in each vignette. Cases were sent via email to a convenience sample of 112 CF clinicians from 13 US CF centers, with 109 clinicians participating (97.3%). 2,792 of the 3,052 cases received a response (91.5%). ANOVA demonstrated variation in rater scores was explained by case scenario and by care center (P < 0.0001). Examining the frequency of each treatment strategy demonstrated no absolute treatment consensus for any given scenario and variability within and between care centers. Direct logistic regression revealed that systemic symptoms (OR = 5.95), decreased O(2) saturation (OR = 4.99) and decreased FEV(1) (OR = 3.78) had a greater effects on the decision to treat a case with IV antibiotics than increased cough/sputum (OR = 2.19) and crackles present on physical examination (OR = 2.10). Similar findings were demonstrated with a cluster analysis. There was surprising variation in the identification and treatment of pulmonary exacerbations by CF clinicians. Variation was present between CF Centers, within each CF center and at the individual clinician level. This study provides additional evidence for the need of a standard definition for a CF pulmonary exacerbation.
目前，临床医生尚未就 CF 肺部加重（pneumonia exacerbation）形成统一的标准定义。本研究旨在调查美国 CF 临床医生在 CF 加重的诊断和治疗方面的临床实践差异。我们采用临床病例，研究 CF 加重的识别和治疗是否存在差异，以及 CF 护理中心之间的治疗模式是否存在差异，以及哪些临床因素决定了治疗方法。我们通过改变五个临床因素，设计了 28 个临床病例。在每个病例中，参与者有四种治疗方案可供选择。研究通过电子邮件将病例发送给来自 13 个美国 CF 中心的 112 名 CF 临床医生，其中 109 名医生参与了调查（97.3%）。在收到的 3052 份回复中，有 2792 份（91.5%）来自参与调查的医生。方差分析表明，评分的差异由病例情况和护理中心决定（P < 0.0001）。对每种治疗策略的频率进行检验，结果表明，在任何给定的情况下，都不存在绝对的治疗共识，并且不同护理中心之间也存在差异。直接逻辑回归显示，全身性症状（OR = 5.95）、血氧饱和度降低（OR = 4.99）和 FEV1 降低（OR = 3.78）比咳嗽/咳痰增加（OR = 2.19）和体格检查时出现爆裂音（OR = 2.10）对决定使用 IV 抗生素治疗病例的影响更大。聚类分析也得出了类似的结果。CF 临床医生在识别和治疗肺部加重方面存在明显差异。这种差异不仅存在于不同的 CF 中心之间，还存在于各个 CF 中心内部和个别临床医生之间。本研究进一步证实了制定 CF 肺部加重标准定义的必要性。
