Di Martino Mirko, Ventura Martina, Cappai Giovanna, Lallo Adele, Davoli Marina, Agabiti Nera, Fusco Danilo
a Department of Epidemiology , Lazio Regional Health Service , Roma , Italy.
COPD. 2017 Feb;14(1):86-94. doi: 10.1080/15412555.2016.1202225. Epub 2016 Jul 15.
In moderate-severe chronic obstructive pulmonary disease (COPD), long-acting bronchodilators (LBs) are recommended to improve the quality of life. The aims of this study were to measure adherence to LBs after discharge for COPD, identify determinants of adherence, and compare amounts of variation attributable to hospitals of discharge and primary care providers, i.e. local health districts (LHDs) and general practitioners (GPs). This cohort study was based on the Lazio region population, Italy. Patients discharged in 2007-2011 for COPD were followed up for 2 years. Adherence was defined as a medication possession ratio >80%. Cross-classified models were performed to analyse variation. Variances were expressed as median odds ratios (MORs). An MOR of 1.00 stands for no variation, a large MOR indicates considerable variation. We enrolled 13,178 patients. About 29% of patients were adherent to LBs. Adherence was higher for patients discharged from pneumology wards and for patients with GPs working in group practice. A relevant variation between LHDs (MOR = 1.21, p = 0.001) and GPs (MOR = 1.28, p = 0.035) was detected. When introducing the hospital of discharge in the model, the MOR related to LHDs decreased to 1.05 (p = 0.345), MOR related to GPs dropped to 1.22 (p = 0.086), whereas MOR associated with hospitals of discharge was 1.38 (p < 0.001). Treatments with proven benefit for COPD were underused. Moreover, a relevant geographic variation was observed. This heterogeneity raises equity concerns in access to optimal care. The reduction of variability among LHDs and GPs after entering the hospital level proved that differences we observe in primary care partially 'reflect' the clinical approach of hospitals of discharge.
在中重度慢性阻塞性肺疾病（COPD）中，推荐使用长效支气管扩张剂（LB）来改善生活质量。本研究的目的是测量COPD患者出院后对LB的依从性，确定依从性的决定因素，并比较出院医院和基层医疗服务提供者（即地方卫生区（LHD）和全科医生（GP））导致的变异量。这项队列研究基于意大利拉齐奥地区的人群。对2007 - 2011年因COPD出院的患者进行了2年的随访。依从性定义为药物持有率>80%。采用交叉分类模型分析变异情况。方差以中位数比值比（MOR）表示。MOR为1.00表示无变异，较大的MOR表明存在显著变异。我们纳入了13178名患者。约29%的患者对LB治疗依从。从肺病科病房出院的患者以及在团体执业中工作的全科医生的患者依从性更高。检测到LHD（MOR = 1.21，p = 0.001）和全科医生（MOR = 1.28，p = 0.035）之间存在显著变异。当在模型中引入出院医院时，与LHD相关的MOR降至1.05（p = 0.345），与全科医生相关的MOR降至1.22（p = 0.086），而出院医院相关的MOR为1.38（p < 0.001）。对COPD有已证实益处的治疗方法未得到充分利用。此外，观察到显著的地理变异。这种异质性引发了对获得最佳治疗的公平性担忧。纳入医院层面后LHD和全科医生之间变异的减少证明，我们在基层医疗中观察到的差异部分地 “反映” 了出院医院的临床治疗方法。
