Department of Respiratory and Critical Care Medicine, Shanghai Institute of Respiratory Disease, Zhongshan Hospital, Fudan University, Shanghai, China Department of Respiratory and Critical Care Medicine, the Affiliated Hospital of Qingdao University, Qingdao, China
Pulmonary and Critical Care Medicine, Qingpu Branch of Zhongshan Hospital, Fudan University, Shanghai, China.
Ther Adv Respir Dis. 2022 Jan-Dec;16:17534666221075499. doi: 10.1177/17534666221075499.
The Chinese government has promoted the 'tiered medical services' policy in which diseases are classified by severity, mode of onset and difficulty of treatment since 2015 to optimize medical resources. We evaluated the diagnosis and treatment of acute exacerbation (AE) of chronic obstructive pulmonary disease (AECOPD) under the tiered system.
We conducted a cross-sectional study. COPD characteristics and treatments were compared among hospitals in different tiers. Associations were examined by univariate and multivariable logistic regression analysis. In addition, multivariate logistic regression was performed to identify the possible influencing factors of antibiotics, glucocorticoids and anticoagulant usages.
Eligible COPD patients ( = 432) were consecutively recruited from eight hospitals in different tiers in China. Patients in the countryside preferred the community hospitals, whereas patients in cities preferred second-tier and teaching hospitals when they suffer from AECOPD. It indicates most COPD patients are likely to treat their disease locally. The severity of COPD AE increased with tiers of hospitals ( < 0.001). However, our results clearly show that most community hospitals can only deal with mild exacerbation of COPD. Approximately 90% of AE patients received antibiotics. We speculated that antibiotics abuse might exist in the three tiers of hospitals. Multivariate analysis demonstrated that long-term antibiotics usage (⩾14 days) was associated with moderate exacerbation [odds ratio (OR): 5.295, 95% confidence intervals (CI) 2.248-12.473, < 0.001], radiographic progression (OR: 2.176, 95% CI: 1.047-4.522, = 0.037), positive sputum etiology (OR: 3.073, 95% CI: 1.477-6.394, = 0.003) and increased white blood cells (OR: 2.470, 95% CI: 1.190-5.126, = 0.015). The proportion of glucocorticoids increased with the hospital hierarchy (18.6% 45.6% 69.2%, < 0.001). The proportions of severe cases in the second-tier hospitals were 26.9%; however, non-invasive positive pressure ventilation (NPPV) rate was only 14.7%. Anticoagulant is not commonly used in AECOPD, and the community hospitals had the lowest proportion of anticoagulation regimen (1.7% 14.3% 20.5%, = 0.002).
The 'tiered medical services' policy in AECOPD management has been unsatisfactory in the past years. Irrational treatment strategies in different hospitals were still found when comparing with international guideline. Further reform of the policy is still needed to optimize the management of AECOPD in China.
自 2015 年以来，中国政府推行了“分级医疗服务”政策，根据疾病的严重程度、发病方式和治疗难度对疾病进行分类，以优化医疗资源。我们评估了分级系统下慢性阻塞性肺疾病急性加重（AECOPD）的诊断和治疗。
我们进行了一项横断面研究。比较了不同层级医院的 COPD 特征和治疗方法。采用单因素和多因素逻辑回归分析来检验关联。此外，还进行了多变量逻辑回归分析，以确定抗生素、糖皮质激素和抗凝剂使用的可能影响因素。
从中国 8 家不同层级的医院连续招募了 432 名符合条件的 COPD 患者。农村患者更喜欢社区医院，而城市患者在患 AECOPD 时更喜欢二级和教学医院。这表明大多数 COPD 患者可能会在当地治疗他们的疾病。AECOPD 的严重程度随着医院的层级而增加（ < 0.001）。然而，我们的结果清楚地表明，大多数社区医院只能处理 COPD 的轻度加重。大约 90%的 AE 患者接受了抗生素治疗。我们推测，抗生素滥用可能存在于三个层级的医院中。多因素分析表明，长期使用抗生素（≥14 天）与中度加重有关[比值比（OR）：5.295，95%置信区间（CI）：2.248-12.473， < 0.001]、影像学进展（OR：2.176，95%CI：1.047-4.522， = 0.037）、痰病原阳性（OR：3.073，95%CI：1.477-6.394， = 0.003）和白细胞增多（OR：2.470，95%CI：1.190-5.126， = 0.015）。糖皮质激素的比例随着医院等级的增加而增加（18.6% 45.6% 69.2%， < 0.001）。二级医院的重症比例为 26.9%；然而，无创正压通气（NPPV）的使用率仅为 14.7%。AECOPD 中抗凝剂不常用，社区医院抗凝方案的比例最低（1.7% 14.3% 20.5%， = 0.002）。
在过去几年中，AECOPD 管理中的“分级医疗服务”政策并不令人满意。与国际指南相比，我们仍然发现不同医院的治疗策略不合理。仍需要对该政策进行进一步改革，以优化中国 AECOPD 的管理。
