基于医护一体化的教育与管理提高支气管哮喘控制:一项真实世界的前瞻性队列研究

Education and management of medical care integration to improve asthma control:a prospective cohort study in a real-world setting

目的评价医护一体化的教育与管理对门诊患者支气管哮喘控制水平的影响。方法基于澳亚重症哮喘协作网真实世界前瞻性队列研究,连续纳入516例成人哮喘患者,采用医护一体化哮喘教育和管理及阶梯治疗策略,入组后1、3、6和12月进行随访,评价用药依从性、肺功能、哮喘症状控制和哮喘急性发作事件。结果与基线比较,随访期结束时患者用药依从性(47.7%vs.81.5%,P<0.05)、肺功能和症状控制明显改善[ACT:20(16,23)vs.23(21,24),P<0.05;ACQ:0.67(0.17,1.50)vs.0.17(0,0.50),P<0.05],86.0%哮喘患者获得完全或良好控制。随访12个月时,哮喘急性发作(14.2%vs.36.2%,P<0.01)、住院(8.5%vs.15.3%,P<0.01)较过去1年明显减少。多元回归分析发现,较低的用药依从性[RR=1.52,95%CI(1.02,2.25),P=0.039]、抑郁症状[RR=1.19,95%CI(1.05,1.34),P=0.007]和过去12月急性发作[RR=2.81,95%CI(1.49,5.27),P=0.001]是未来哮喘急性发作的独立危险因素。结论在真实世界,通过医生与患者的共同决策,按照哮喘阶梯治疗策略,加强医护一体化的哮喘教育和管理,绝大部分哮喘患者可获得完全或良好控制。较低用药依从性和抑郁症状是哮喘急性发作的独立危险因素,加强医护一体化的哮喘管理,尤其是心理护理,或许是进一步提高哮喘控制的有效途径。

Objective To explore whether education and management of medical care integration can improve asthma control.Methods A prospective,12-month,cohort study was undertaken in a real-world setting based on Australasian severe asthma network(ASAN).A total of 516 patients with stable asthma were consecutively recruited,who received education and management of medical care integration,and step-wise anti-asthma regimens determined by physicians’standard practice.Furthermore,inhaled corticosteroid(ICS)adherence,lung function,asthma symptom control and exacerbation were assessed at 1,3,6,and 12 months.Results At the end of 12 months,ICS adherence(47.7%vs.81.5%,P<0.05),lung function,and asthma symptoms were assessed by asthma control text(ACT)[20(16,23)vs.23(21,24),P<0.05],which were significantly improved in comparison to the status at baseline,and 86.0%of patients achieved total/well-controlled level of asthma.The exacerbation(14.2%vs.36.2%,P<0.01)and hospitalizations(8.5%vs.15.3%,P<0.01)because of asthma for the following year significantly decreased compared with those in the past year.The multivariate regression analysis indicated that poor ICS adherence(RR=1.52,95%CI 1.02 to 2.25,P=0.039),depression symptoms(RR=1.19,95%CI 1.05 to 1.34,P=0.007),and exacerbation during the past year(RR=2.81,95%CI 1.49 to 5.27,P=0.001)were associated with an increased risk of future exacerbation.Conclusion In a real-world setting,most of asthmatics achieve total/well-controlled asthma by education and management of medical care integration including shared decision-making between physicians and patients and step-wise anti-asthma regimens.ICS adherence and depression symptoms independently predict asthma exacerbations,and strengthening education and management of medical care integration,esp.psychological nursing,would improve asthma control levels.