The Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada.
BMJ Open. 2019 Jan 29;9(1):e022506. doi: 10.1136/bmjopen-2018-022506.
Care gaps in asthma may be highly prevalent but are poorly characterised. We sought to prospectively measure adherence to key evidence-based adult asthma practices in primary care, and predictors of these behaviours.
One-year prospective cohort study employing an electronic chart audit.
Three family health teams (two academic, one community-based) in Ontario, Canada.
884 patients (72.1% female; 46.0±17.5 years old) (4199 total visits; 4.8±4.8 visits/patient) assigned to 23 physicians (65% female; practising for 10.0±8.6 years).
The primary outcome was the proportion of visits during which practitioners assessed asthma control according to symptom-based criteria. Secondary outcomes included the proportion of: patients who had asthma control assessed at least once; visits during which a controller medication was initiated or escalated; and patients who received a written asthma action plan. Behavioural predictors were established a priori and tested in a multivariable model.
Primary outcome: Providers assessed asthma control in 4.9% of visits and 15.4% of patients. Factors influencing assessment included clinic site (p=0.019) and presenting symptom, with providers assessing control more often during visits for asthma symptoms (35.0%) or any respiratory symptoms (18.8%) relative to other visits (1.6%) (p<0.01).
Providers escalated controller therapy in 3.3% of visits and 15.4% of patients. Factors influencing escalation included clinic site, presenting symptom and prior objective asthma diagnosis. Escalation occurred more frequently during visits for asthma symptoms (21.0%) or any respiratory symptoms (11.9%) relative to other visits (1.5%) (p<0.01) and in patients without a prior objective asthma diagnosis (3.5%) relative to those with (1.3%) (p=0.025). No asthma action plans were delivered.
Major gaps in evidence-based asthma practice exist in primary care. Targeted knowledge translation interventions are required to address these gaps, and can be tailored by leveraging the identified behavioural predictors.
NCT01070095; Pre-results.
哮喘护理中的差距可能很普遍，但描述不足。我们旨在前瞻性地衡量初级保健中关键循证成人哮喘实践的依从性，并预测这些行为的预测因素。
采用电子图表审核的为期一年的前瞻性队列研究。
加拿大安大略省的三个家庭健康团队（两个学术团队，一个社区团队）。
884 名患者（72.1%为女性；46.0±17.5 岁）（4199 次总就诊；4.8±4.8 次/患者）分配给 23 名医生（65%为女性；行医 10.0±8.6 年）。
主要结局是医生根据基于症状的标准评估哮喘控制情况的就诊比例。次要结局包括：至少一次评估哮喘控制的患者比例；启动或升级控制药物的就诊比例；以及接受书面哮喘行动计划的患者比例。行为预测因素是事先确定的，并在多变量模型中进行了测试。
主要结局：在 4.9%的就诊和 15.4%的患者中，医生评估了哮喘控制情况。影响评估的因素包括诊所地点（p=0.019）和就诊症状，与其他就诊（1.6%）相比，医生在哮喘症状（35.0%）或任何呼吸道症状（18.8%）就诊时更频繁地评估控制情况（p<0.01）。
医生在 3.3%的就诊和 15.4%的患者中升级了控制药物。影响升级的因素包括诊所地点、就诊症状和既往客观哮喘诊断。与其他就诊（1.5%）相比，在哮喘症状就诊（21.0%）或任何呼吸道症状就诊（11.9%）时，升级更频繁（p<0.01），在既往无客观哮喘诊断的患者中（3.5%）比有客观哮喘诊断的患者（1.3%）更频繁（p=0.025）。没有提供哮喘行动计划。
初级保健中存在重大的循证哮喘实践差距。需要有针对性的知识转化干预措施来解决这些差距，并可以通过利用确定的行为预测因素进行调整。
NCT01070095；预结果。
