加拿大渥太华大学Shawn D. Aaron团队研究了COPD和哮喘的早期诊断和治疗对患者预后及医疗保健使用率的影响。相关论文发表在2024年5月19日出版的《新英格兰医学杂志》上。

许多患有慢性阻塞性肺病（COPD）或哮喘的患者尚未得到诊断，因此他们的呼吸道症状在很大程度上仍未得到治疗。

研究组使用病例发现方法来识别社区中有呼吸道症状但未诊断为肺病的成年人。通过肺活量测定发现患有未确诊的COPD或哮喘的参与者被纳入一项多中心、随机、对照试验，以确定早期诊断和治疗是否会减少呼吸道疾病的医疗保健利用率并改善健康预后。参与者被分配接受干预（由肺科医生和哮喘-慢性阻塞性肺病教育者进行评估，他们被指示遵循指南的护理）或由他们的初级保健医生进行常规护理。主要结局是参与者对呼吸系统疾病的医疗保健利用率的年化率。次要结局包括从基线到1年疾病特异性生活质量的变化，如圣乔治呼吸问卷（SGRQ；评分范围从0到100，评分越低表示健康状况越好）所评估的；症状负担，用COPD评估测试（CAT；评分范围从0到40，评分越低表示健康状况越好）评估；以及1秒用力呼气量（FEV1）。

在38353名受访者中，595人被发现患有未确诊的COPD或哮喘，508人接受了随机分组：253人被分配到干预组，255人被分配到常规护理组。干预组主要结局事件的年化发生率低于常规护理组（每人每年0.53次vs1.12次；发病率比率为0.48；95%置信区间[CI]为0.36-0.63；P<0.001）。在12个月时，干预组和常规护理组的SGRQ得分分别比基线得分低10.2分和6.8分（差异，−3.5分；95%置信区间，−6.0至−0.9），CAT得分分别比基准得分低3.8分和2.6分（差异为−1.3分；95%可信区间，−2.4至−0.1）。干预组的FEV1增加了119毫升，常规护理组增加了22毫升（差异为94毫升；95%可信区间为50至138）。试验组的不良事件发生率相似。

在这项试验中，使用一种策略来识别社区中患有未确诊哮喘或COPD的成年人，与接受常规护理的人相比，接受肺科医生指导治疗的人对呼吸道疾病的后续医疗保健利用率较低。

附：英文原文

Title: Early Diagnosis and Treatment of COPD and Asthma — A Randomized, Controlled Trial

Author: Shawn D. Aaron, Katherine L. Vandemheen, G. Alex Whitmore, Celine Bergeron, Louis-Philippe Boulet, Andréanne Cté, R. Andrew McIvor, Erika Penz, Stephen K. Field, Catherine Lemière, Irvin Mayers, Mohit Bhutani, Tanweer Azher, M. Diane Lougheed, Samir Gupta, Nicole Ezer, Christopher J. Licskai, Paul Hernandez, Martha Ainslie, Gonzalo G. Alvarez, Sunita Mulpuru

Issue&Volume: 2024-05-19

Abstract:

BACKGROUND

Many persons with chronic obstructive pulmonary disease (COPD) or asthma have not received a diagnosis, so their respiratory symptoms remain largely untreated.

METHODS

We used a case-finding method to identify adults in the community with respiratory symptoms without diagnosed lung disease. Participants who were found to have undiagnosed COPD or asthma on spirometry were enrolled in a multicenter, randomized, controlled trial to determine whether early diagnosis and treatment reduces health care utilization for respiratory illness and improves health outcomes. Participants were assigned to receive the intervention (evaluation by a pulmonologist and an asthma–COPD educator who were instructed to initiate guideline-based care) or usual care by their primary care practitioner. The primary outcome was the annualized rate of participant-initiated health care utilization for respiratory illness. Secondary outcomes included changes from baseline to 1 year in disease-specific quality of life, as assessed with the St. George Respiratory Questionnaire (SGRQ; scores range from 0 to 100, with lower scores indicating better health status); symptom burden, as assessed with the COPD Assessment Test (CAT; scores range from 0 to 40, with lower scores indicating better health status); and forced expiratory volume in 1 second (FEV1).

RESULTS

Of 38,353 persons interviewed, 595 were found to have undiagnosed COPD or asthma and 508 underwent randomization: 253 were assigned to the intervention group and 255 to the usual-care group. The annualized rate of a primary-outcome event was lower in the intervention group than in the usual-care group (0.53 vs. 1.12 events per person-year; incidence rate ratio, 0.48; 95% confidence interval [CI], 0.36 to 0.63; P<0.001). At 12 months, the SGRQ score was lower than the baseline score by 10.2 points in the intervention group and by 6.8 points in the usual-care group (difference, 3.5 points; 95% CI, 6.0 to 0.9), and the CAT score was lower than the baseline score by 3.8 points and 2.6 points, respectively (difference, 1.3 points; 95% CI, 2.4 to 0.1). The FEV1 increased by 119 ml in the intervention group and by 22 ml in the usual-care group (difference, 94 ml; 95% CI, 50 to 138). The incidence of adverse events was similar in the trial groups.

CONCLUSIONS

In this trial in which a strategy was used to identify adults in the community with undiagnosed asthma or COPD, those who received pulmonologist-directed treatment had less subsequent health care utilization for respiratory illness than those who received usual care.

DOI: NJ202405190000007

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa2401389