Koefoed Mette Marie
Institute of public health, Faculty of Health Sciences, University of Southern Denmark, J.B. Winsløws Vej 9A, 5000 Odense C, Denmark.
Dan Med J. 2015 Feb;62(2).
This PhD thesis was written during my employment at the Research Unit of General Practice in Odense, University of Southern Denmark. It comprises an overview and three papers, all published or submitted for publication in international peer-reviewed scientific journals.
Non-infectious dyspnoea, chronic cough and wheezing are common symptoms in the population. Patients often present with these symptoms in general practice and have a high probability of having obstructive lung diseases. However, there is an indication that the majority of these patients are treated empirically with pharmacotherapy targeting obstructive lung disease and only few have additional tests conducted, although the predictive value of respiratory symptoms for diagnosing obstructive lung disease has proven to be low. Spirometry is recommended as the gold standard for confirming obstructive lung disease, and testing can also rule out airway obstruction in patients with respiratory symptoms caused by other illnesses, such as heart failure or lung cancer. Initiating medication for obstructive lung disease without spirometry entails the risk of these patients experiencing unnecessary delay in the diagnostic process and being exposed to unnecessary economic costs and medication risks. The literature has indicated that many users of medication targeting obstructive lung medication have not had spirometry performed and do not actually have obstructive lung disease. This potential quality gap needs to be assessed. Also, in order to target interventions enhancing earlier spirometry utilisation among patients initiating medication targeting obstructive lung disease, improved knowledge on patient and practice factors associated with spirometry testing is needed.
Among first time users of obstructive lung medication we aimed: - To assess to what extent spirometry was performed within the first year of medication use (Study I) - To assess if patient characteristics like socioeconomic and demographic status were associated with spirometry testing (Studies I &II) - To assess if general practice characteristics were associated with spirometry testing (Study III)
Register-based observational studies on first time users of medication targeting obstructive lung disease among adults over 18 years of age in 2008. The patient cohort was identified in the Danish National Prescription Register where all redeemed prescriptions for medication targeting obstructive lung disease are registered. All spirometry tests provided to the patient cohort in the time period 2007-2010 were extracted from the Danish National Health Service Register and the Danish National Patient Register and we assessed if patients had a spirometry registered in an 18- month time period counting from 6 months before to 12 months after their first redemption of medication. We linked socioeconomic and demographic patient variables and variables on practice characteristics from National registers to assess their association with patients having spirometry performed.
A total of 40,969 adults initiated medication targeting obstructive lung medication in 2008 in Denmark. The mean age of the cohort was 55.6 years (SD18.7) and approximately half of the mediations users had spirometry test performed. Initiating several types of medication targeting obstructive lung disease within the first year and redeeming medication repeatedly increased the odds of having spirometry performed. Women and patients in the oldest age categories had reduced odds of having spirometry performed. Being unemployed reduced the odds for spirometry testing among adults less than 65 years of age. Also, among the elderly (>65 years) living alone reduced the odds for spirometry testing; however this was only statistically significant among men. Some practice characteristics also influenced the odds for spirometry testing. Patients in partnership practices had higher odds for spirometry testing. Among singlehanded practices higher odds for spirometry testing was seen if practice had training practice status. We saw decreasing odds for spirometry testing with increasing age among doctors.
This study has shown a lack of spirometry testing among patients initiating medication targeting obstructive lung disease. This underuse of spirometry testing indicates a quality gap and increased focus of spirometry utilization is needed when patients initiate medication targeting obstructive lung disease. The variation reported in spirometry testing across patient and practice characteristics was most predominant with regard to increasing age among patients and doctors, the remaining variables only account for small variations. However identification of these variations can help guide general practitioners to identify patients at increased risk of not having spirometry performed and help target future interventions for primary care.
本博士论文是我在南丹麦大学欧登塞全科医学研究单位任职期间撰写的。它包括一篇综述和三篇论文，均已发表或已提交至国际同行评审科学期刊发表。
非感染性呼吸困难、慢性咳嗽和喘息是人群中的常见症状。患者常在全科医疗中出现这些症状，且很有可能患有阻塞性肺疾病。然而，有迹象表明，这些患者中的大多数仅接受针对阻塞性肺疾病的经验性药物治疗，只有少数患者进行了额外检查，尽管呼吸症状对阻塞性肺疾病的诊断预测价值已被证明较低。肺活量测定被推荐为确诊阻塞性肺疾病的金标准，该检查还可排除由其他疾病（如心力衰竭或肺癌）引起的呼吸症状患者的气道阻塞情况。在未进行肺活量测定的情况下就开始使用治疗阻塞性肺疾病的药物，会使这些患者面临诊断过程不必要的延误风险，并承受不必要的经济成本和用药风险。文献表明，许多使用治疗阻塞性肺疾病药物的患者并未进行肺活量测定，实际上也并未患有阻塞性肺疾病。这种潜在的质量差距需要进行评估。此外，为了针对那些开始使用治疗阻塞性肺疾病药物的患者提高肺活量测定的早期使用率，需要更好地了解与肺活量测定相关的患者因素和医疗实践因素。
针对首次使用阻塞性肺疾病药物的患者，我们的目标是： - 评估在用药的第一年内进行肺活量测定的程度（研究一） - 评估社会经济和人口统计学等患者特征是否与肺活量测定相关（研究一和二） - 评估全科医疗特征是否与肺活量测定相关（研究三）
基于登记的观察性研究，研究对象为2008年18岁以上首次使用阻塞性肺疾病药物的成年人。患者队列是在丹麦国家处方登记处确定的，该登记处记录了所有已兑现的治疗阻塞性肺疾病药物的处方。2007 - 2010年期间提供给该患者队列的所有肺活量测定检查均从丹麦国家卫生服务登记处和丹麦国家患者登记处提取，我们评估患者在首次兑现药物前6个月至首次兑现药物后12个月的18个月时间段内是否进行了肺活量测定登记。我们将社会经济和人口统计学患者变量以及来自国家登记处的医疗实践特征变量相联系，以评估它们与进行肺活量测定的患者之间的关联。
2008年丹麦共有40,969名成年人开始使用阻塞性肺疾病药物。该队列的平均年龄为55.6岁（标准差18.7），约一半的药物使用者进行了肺活量测定检查。在第一年内开始使用多种类型的阻塞性肺疾病药物以及多次兑现药物会增加进行肺活量测定的几率。女性和年龄最大的年龄组患者进行肺活量测定的几率降低。失业会降低65岁以下成年人进行肺活量测定的几率。此外，在老年人（>65岁）中，独居会降低进行肺活量测定的几率；然而，这仅在男性中具有统计学意义。一些医疗实践特征也会影响进行肺活量测定的几率。在合伙经营的诊所中，患者进行肺活量测定的几率更高。在单人执业诊所中，如果诊所具有培训诊所的地位，则进行肺活量测定的几率更高。我们发现随着医生年龄的增加，进行肺活量测定的几率逐渐降低。
本研究表明，在开始使用阻塞性肺疾病药物的患者中，肺活量测定检查不足。这种肺活量测定检查的未充分利用表明存在质量差距，当患者开始使用阻塞性肺疾病药物时，需要更加关注肺活量测定的使用率。在肺活量测定检查方面，患者和医疗实践特征的差异在患者和医生年龄增加方面最为显著，其余变量仅占很小的差异。然而，识别这些差异有助于指导全科医生识别未进行肺活量测定风险增加的患者，并有助于针对初级保健进行未来的干预。
