未遵循原始全球慢性阻塞性肺疾病倡议（GOLD）治疗指南与慢性阻塞性肺疾病（COPD）急性加重之间的负相关关系。
Inverse relationship between nonadherence to original GOLD treatment guidelines and exacerbations of COPD.
作者信息
Foda Hussein D, Brehm Anthony, Goldsteen Karen, Edelman Norman H
机构信息
Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Veterans Affairs Medical Center, Northport; Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Stony Brook University Medical Center, Stony Brook, NY.
MPH Program, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND.
出版信息
Int J Chron Obstruct Pulmon Dis. 2017 Jan 6;12:209-214. doi: 10.2147/COPD.S119507. eCollection 2017.
BACKGROUND
Prescriber disagreement is among the reasons for poor adherence to COPD treatment guidelines; it is yet not clear whether this leads to adverse outcomes. We tested whether undertreatment according to the original Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines led to increased exacerbations.
METHODS
Records of 878 patients with spirometrically confirmed COPD who were followed from 2005 to 2010 at one Veterans Administration (VA) Medical Center were analyzed. Analysis of variance was performed to assess differences in exacerbation rates between severity groups. Logistic regression analysis was performed to assess the relationship between noncompliance with guidelines and exacerbation rates.
FINDINGS
About 19% were appropriately treated by guidelines; 14% overtreated, 44% under-treated, and in 23% treatment did not follow any guideline. Logistic regression revealed a strong inverse relationship between undertreatment and exacerbation rate when severity of obstruction was held constant. Exacerbations per year by GOLD stage were significantly different from each other: mild 0.15, moderate 0.27, severe 0.38, very severe 0.72, and substantially fewer than previously reported.
INTERPRETATION
The guidelines were largely not followed. Undertreatment predominated but, contrary to expectations, was associated with fewer exacerbations. Thus, clinicians were likely advancing therapy primarily based upon exacerbation rates as was subsequently recommended in revised GOLD and other more recent guidelines. In retrospect, a substantial lack of prescriber adherence to treatment guidelines may have been a signal that they required re-evaluation. This is likely to be a general principle regarding therapeutic guidelines. The identification of fewer exacerbations in this cohort than has been generally reported probably reflects the comprehensive nature of the VA system, which is more likely to identify relatively asymptomatic (ie, nonexacerbating) COPD patients. Accordingly, these rates may better reflect those in the general population. In addition, the lower rates may reflect the more complete preventive care provided by the VA.
背景
处方医生意见不一致是慢性阻塞性肺疾病（COPD）治疗指南依从性差的原因之一；目前尚不清楚这是否会导致不良后果。我们测试了按照最初的慢性阻塞性肺疾病全球倡议（GOLD）指南进行的治疗不足是否会导致病情加重。
方法
分析了878例经肺功能检查确诊为COPD的患者的记录，这些患者于2005年至2010年在一家退伍军人事务部（VA）医疗中心接受随访。进行方差分析以评估严重程度组之间病情加重率的差异。进行逻辑回归分析以评估不符合指南与病情加重率之间的关系。
结果
约19%的患者得到了指南的适当治疗；14%的患者治疗过度，44%的患者治疗不足，23%的患者治疗未遵循任何指南。逻辑回归显示，在阻塞严重程度保持不变的情况下，治疗不足与病情加重率之间存在强烈的负相关关系。按GOLD分期每年的病情加重情况差异显著：轻度为0.15，中度为0.27，重度为0.38，极重度为0.72，且明显低于先前报道。
解读
这些指南在很大程度上未得到遵循。治疗不足占主导，但与预期相反，其与较少的病情加重相关。因此，临床医生可能主要根据病情加重率推进治疗，正如修订后的GOLD指南和其他更新的指南随后所建议的那样。回顾过去，处方医生对治疗指南的严重缺乏依从性可能表明这些指南需要重新评估。这可能是治疗指南的一个普遍原则。该队列中病情加重情况少于一般报道，这可能反映了VA系统的全面性，该系统更有可能识别相对无症状（即未加重）的COPD患者。因此，这些发生率可能更好地反映了普通人群中的情况。此外，较低的发生率可能反映了VA提供的更全面的预防保健。
Zotero 插件