Care Fragmentation Is Associated with Increased Chronic Obstructive Pulmonary Disease Exacerbations in a U.S. Urban Care Setting.
Care Fragmentation Is Associated with Increased Chronic Obstructive Pulmonary Disease Exacerbations in a U.S. Urban Care Setting.
复制标题
在美国城市护理环境中，护理碎片化与慢性阻塞性肺疾病加重有关。
DOI：
10.1164/rccm.202112-2807le
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发表时间：
2022
影响因子：
24.7
通讯作者：
Kalhan,Ravi
中科院分区：
文献类型：
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作者：
Young,KarenC;Meza,DanielA;Khuder,Basil;Rosenberg,SharonR;Liu,GabrielleY;Kruser,JacquelineM;Reyfman,PaulA;Kalhan,Ravi
在美国城市护理环境中，护理碎片化与慢性阻塞性肺疾病加重增加相关，并区分一种疾病与另一种疾病，或者当它提供预测与特定疾病相关的重要临床结局的预后信息时。BDR最常用于支持存在气流阻塞的哮喘诊断。然而，COPD患者中BDR的高患病率显著降低了该适应症的特异性;事实上，在COPDGene队列中，约有一半符合新的BDR标准。新标准的预期价值在于，使用肺功能的百分比预测变化将减少肺部疾病严重程度对BDR的影响。这一考虑导致在2005年安非他明类兴奋剂定义中要求结合绝对和相对变化标准。引用的预后研究用于支持根据FEV 1/FVC比值调整的标准变化，该比值与气流阻塞的严重程度不呈线性相关，该研究在单中心进行，仅包括白色个体（7）。事实上，几项研究表明，当根据潜在肺部疾病的严重程度进行调整时，BDR反应在临床上没有用处（8，9）。汉森及其同事表明，当模型调整为最佳肺量测定时，通常是在使用支气管扩张剂后，阳性BDR在预测生存率方面的价值被消除（8）。我们最近发现，与无BDR的个体相比，合并BDR的个体（FEV 1和FVC的百分比和体积标准均为阳性反应）肺气肿较少，中度和重度急性发作更频繁，死亡率更低，与哮喘样表型相符（9）。在目前的研究中，我们发现，当调整肺部疾病的严重程度时，目前或拟议的BDR标准都不能预测COPD的急性加重或死亡率。该研究的优势包括严格的肺量测定质量控制和前瞻性的结局数据收集。这项研究有一些局限性。肺量测定前未统一停用支气管扩张剂。这不应影响结果，因为技术标准文件中引用的既往研究也未停用支气管扩张剂。此外，停用支气管扩张剂对于在诊断时记录可逆性与不可逆性气流阻塞至关重要，但对确定疾病严重程度没有太大价值。总之，目前和拟定的ERS/ATS支气管扩张剂反应性标准均不能提供COPD的预后价值。如果临床应用是为了增强诊断或鉴别，则需要提高BDR标准的特异性。
Care Fragmentation Is Associated with Increased Chronic Obstructive Pulmonary Disease Exacerbations in a US Urban Care Setting and differentiate one disease from another, or when it offers prognostic information for predicting important clinical outcomes associated with a specific disease. BDR is most frequently used to support a diagnosis of asthma in the presence of airflow obstruction. The high prevalence of BDR in individuals with COPD, however, decreases the specificity for this indication significantly; indeed, approximately half met the new BDR criteria in the COPDGene cohort. The purported value of the new criterion is that the using the percentage predicted change in lung function would decrease the influence of the severity of lung disease on BDR. This consideration had resulted in the requirement for the combined absolute and relative change criteria in the 2005 ATS definition. The prognostic study cited to support the change in criteria adjusted for the FEV1/FVC ratio which is not linearly associated with the severity of airflow obstruction, was conducted at a single center, and included only White individuals (7). Indeed, several studies have shown that a BDR response is not clinically useful when adjusted for the severity of underlying lung disease (8, 9). Hansen and colleagues showed that when models were adjusted for the best spirometry effort, which was often post-bronchodilator, the value of a positive BDR in predicting survival was erased (8). We recently showed that, compared with individuals with no BDR, those with a combined BDR (a positive response in percentage and volume criteria for both FEV1 and FVC) have less emphysema and have more frequent moderate and severe exacerbations as well as lower mortality, compatible with an asthma-like phenotype (9). In the current study, we found that neither the current nor the proposed BDR criteria predicted exacerbations or mortality in COPD when adjusted for the severity of lung disease. The strengths of the study include the stringent quality control of spirometry and the prospective collection of outcomes data. The study has a few limitations. Bronchodilators were not uniformly withheld prior to spirometry. This should not distract from the results as prior studies cited in the technical standard document also did not withhold bronchodilators. Furthermore, withholding bronchodilators is critical for documenting reversible versus irreversible airflow obstruction at the time of diagnosis but does not add much value for determining disease severity. In conclusion, both the current and the proposed ERS/ATS criteria for bronchodilator responsiveness do not offer prognostic value in COPD. If the clinical application is to enhance diagnosis or prognostication, there is a need for increased specificity in the BDR criteria.■