Smeele I J, Van Schayck C P, Van Den Bosch W J, Van Den Hoogen H J, Muris J W, Grol R P
Werkgroep Onderzoek Kwaliteit, Katholieke Universiteit, Nijmegen.
Ned Tijdschr Geneeskd. 1998 Oct 17;142(42):2304-8.
To analyse to what extent current management of exacerbation in adult asthmatics and patients with asthma or chronic obstructive pulmonary disease (COPD) in general practice is consistent with the guidelines from the standard 'asthma/COPD in adults' of the Dutch College of General Physicians (NHG).
Cross-sectional, prospective.
Centre for Quality of Care Research, University of Nijmegen, the Netherlands.
Fifty-two GPs in 1992 during an average of 3.5 months in adult patients with exacerbation of asthma or COPD prospectively registered the severity of the dyspnoea, productiveness of coughing, colour of phlegm, fever, auscultatory findings, patients' age and sex and use of medication. Current management (peak flow measurement, prescriptions) was related to all these data and compared with that recommended in the current NHG standard.
Data were available on 383 exacerbations. Peak flow measurement was used diagnostically in 27% of the exacerbations. Inhalation steroids were prescribed in 26% of the cases (new or step-up), oral steroids were prescribed in 24%, more often in exacerbations with severe dyspnoea (48%; p < 0.0005), in patients who prior to the exacerbations had been using two or more different COPD drugs (37%; p < 0.0005) and in patients over 55 years of age (35%; p < 0.0005). Antibiotics were prescribed in 60% of the cases, and more often in case of coloured phlegm (83%; p < 0.0005) and of fever (91%; p < 0.0005).
Objectivation of the bronchial obstruction by peak flow measurement was done less often than recommended in the standard; antibiotics were prescribed more often and steroids less often. In order to reduce the substantial discrepancy between the guidelines and the actual management, implementation should be aimed at changing GPs' routines, with special attention for barriers to change.
分析在成人哮喘患者以及一般诊疗中的哮喘或慢性阻塞性肺疾病（COPD）患者中，当前对病情加重的管理在多大程度上符合荷兰全科医师学院（NHG）“成人哮喘/COPD”标准指南。
横断面、前瞻性研究。
荷兰奈梅亨大学医疗质量研究中心。
1992年，52名全科医生在平均3.5个月的时间里，对哮喘或COPD病情加重的成年患者前瞻性地记录了呼吸困难的严重程度、咳嗽咳痰情况、痰液颜色、发热情况、听诊结果、患者年龄和性别以及用药情况。将当前的管理措施（峰值流速测量、处方）与所有这些数据相关联，并与当前NHG标准中推荐的措施进行比较。
有383次病情加重的数据。在27%的病情加重中使用了峰值流速测量进行诊断。26%的病例开具了吸入性类固醇（新处方或剂量增加），24%的病例开具了口服类固醇，在严重呼吸困难的病情加重中更常开具（48%；p<0.0005），在病情加重前使用两种或更多不同COPD药物的患者中更常开具（37%；p<0.0005），在55岁以上的患者中更常开具（35%；p<0.0005）。60%的病例开具了抗生素，在痰液有颜色（83%；p<0.0005）和发热（91%；p<0.0005）的情况下更常开具。
通过峰值流速测量对支气管阻塞进行客观评估的频率低于标准中推荐的频率；抗生素的开具更为频繁，而类固醇的开具则较少。为了减少指南与实际管理之间的巨大差异，实施工作应旨在改变全科医生的常规做法，并特别关注变革的障碍。
