Primary Care Respiratory Journal最新文献

Background: Few data exist on the understanding and adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines in resource-limited settings, which are mostly in sub-Saharan Africa.

Objectives: To assess physicians' understanding, adherence, and barriers to implementation of GOLD guidelines in Nigeria.

Methods: A questionnaire based on the recommendations of the guidelines was self-administered by 156 physicians in departments of internal and family medicine in selected hospitals to assess physician understanding of the GOLD guidelines and barriers to its implementation. The medical records of patients with chronic obstructive pulmonary disease (COPD) were also reviewed to assess adherence to the guideline recommendations.

Results: The performance score of all physicians was 22.37±0.39 (range 0-38). Pulmonologists had the highest score (37.00±0.00) while medical officers had the lowest score (19.93±4.98) (F=10.16, df=5, p<0.001). Forty one percent of physicians knew the spirometric criteria for diagnosing COPD and 26.9% could assess the severity. In clinical practice, 32% of patients had brief smoking counselling despite 70% being smokers, 24% had spirometry and 18% had assessment of severity. Almost 60% of patients were on oral aminophylline, 72% were on an inhaled long-acting β2-agonist and corticosteroid combination, 2% had pulmonary rehabilitation and no patients were vaccinated. Self-reported adherence to the COPD guidelines was 23.7%. Lack of familiarity (39.8%) was cited as the most common barrier to adherence to the guidelines.

Conclusions: The understanding of GOLD guidelines is satisfactory among Nigerian doctors managing patients with COPD but the level of adherence is poor. Educational interventions are needed to improve the implementation of guideline-based management.

Background: There are ongoing concerns about the quality of care provision for allergy in primary care.

Aims: To identify current training provision in allergy to GP trainees and to understand how this could be enhanced.

Methods: A cross-sectional survey of GP Speciality Training (GPST) programme directors was undertaken. Programme directors of the 174 GPST schemes were sent an online questionnaire which was informed by the content of the Royal College of General Practitioners curriculum. Quantitative data were descriptively analysed and a thematic analysis was undertaken of free text responses.

Results: We obtained responses from 146 directors representing 106 training programmes. Responses indicated that two-thirds (62%, 95% CI 53.1 to 71.5) of programmes were providing at least some allergy training, with the remaining third stating that they either provided no training or were unsure. Overall, one-third (33%, 95% CI 22.7 to 42.2) of programme directors believed that all the relevant allergy-related curriculum requirements were being met. Where provided, this training was believed to be best for organ-specific allergic disorders but was thought to be poorer for systemic allergic disorders, particularly food allergy where 67% (95% CI 57.5 to 76.5) of respondents indicated that training was poor. There was considerable interest in increasing the allergy training provided, preferably through eLearning modules and problem-based learning materials supported by those with relevant specialist knowledge.

Conclusions: This UK-wide survey has identified important gaps in the training of GP trainees in relation to allergy care. Addressing these gaps, particularly in the management of systemic allergic disorders, should help to improve delivery of primary care-based allergy care.

Background: Allergic rhinitis (AR) and asthma are both inflammatory diseases and are often associated. Relationships between fractional exhaled nitric oxide (FeNO) and asthma, atopy, and quality of life have been shown.

Aims: This study aimed to determine whether FeNO in children with AR (n=158) or combined AR and asthma (n=93) was associated with clinical symptoms, house dust mite (HDM)-specific IgE, and rhinitis-specific quality of life, both cross-sectionally and longitudinally.

Methods: Children with AR aged 6-18 years (n=251) in primary care were assessed for FeNO, nasal symptom scores, asthma symptom scores, quality of life, and HDM-specific IgE at baseline and 2 years later.

Results: We found similarly elevated FeNO in children with only AR and in those with combined AR and asthma. No correlations were found between FeNO and nasal or asthma symptoms and rhinitis-related quality of life. Longitudinal correlations were strongest for HDM-specific IgE (r=0.91, p<0.0001).

Conclusions: FeNO was similar in a selected group of children with AR with and without asthma in primary care and was unrelated to symptoms or quality of life in both groups. FeNO is unlikely to be a useful biomarker of the clinical severity of upper or lower airway disease in primary care.

Background: Secondary care physicians caring for people with long-term conditions (LTCs) are under increasing pressure to discharge long-term follow-up patients to primary care. In respiratory medicine, the 2008 British Thoracic Society (BTS) statement on criteria for specialist referral, admission, discharge, and follow-up for adults with respiratory disease remains the only available basis for this dialogue. There is widespread concern about reforming outpatient clinics to meet these demands and the impact of discharging people with respiratory LTCs to primary care.

Aims: To examine the impact of implementing BTS guidance on secondary care follow-up of patients with respiratory disease.

Methods: We undertook a clinic reform project, which included one-stop medical reviews, providing more open access appointments, and implementing the BTS criteria. The impact on patients was assessed by patient survey, and the impact on GPs was assessed by an analysis of referral patterns pre- and post-reform.

Results: There was a significant improvement in commissioner-mandated performance through reduction in follow-up (p=0.006) and the unscheduled hospital admission rate decreased significantly (p=0.021). However, many patients were dissatisfied with the process and re-referral rates rose.

Conclusions: Our findings suggest that the delivery of a responsive service capable of sustainable management of respiratory LTCs can be achieved using the BTS criteria. It seems to be efficacious within secondary care, increasing the quality and value of the clinic activity, although hidden impacts on primary care will require further prospective studies.

Background: One of the aims of the COPD Assessment Test (CAT) is to aid communication between the physician and patient about the burden of chronic obstructive pulmonary disease (COPD) on the patient's life.

Aims: To investigate the impact of the CAT on the quality of primary care consultations in COPD patients.

Methods: Primary care physicians across Europe conducted six consultations with standardised COPD patients (played by trained actors). Physicians were randomised to see the patient with the completed CAT (CAT+ arm) or without (no CAT arm) during the consultation. These were videoed and independent assessors scored the physicians on their ability to identify and address patient-specific issues such as depression (sub-score A); review standard COPD issues such as breathlessness (sub-score B); their understanding of the case (understanding score); and their overall performance. The primary endpoint was the global score (sub-scores A+B; scale range 0-40).

Results: A total of 165 physicians enrolled in the study and carried out six consultations each; 882 consultations were deemed suitable for analysis. No difference was seen between the arms in the global score (no CAT arm 20.3; CAT+ arm 20.7; 95% CI -1.0 to 1.8; p=0.606) or on sub-score A (p=0.255). A statistically significant difference, though of limited clinical relevance, was observed in mean sub-score B (no CAT arm 8.8; CAT+ arm 9.6; 95% CI 0.0 to 1.6; p=0.045). There was no difference in understanding score (p=0.824) or overall performance (p=0.655).

Conclusions: The CAT is a disease-specific instrument that aids physician assessment of COPD. It does not appear to improve detection of non-COPD symptoms and co-morbidities.

Background: Quality improvement, standardisation of spirometry testing, and interpretation of results are critically important in the occupational setting.

Aims: To determine the quality of spirometry tests and pulmonary function changes in two consecutive years among the personnel of an industrial company.

Methods: This study was performed in an oil refinery in Iran in 2011. Data on 1,004 male personnel were evaluated before and after a training course conducted according to the National Institute for Occupational Safety and Health guidelines. American Thoracic Society/European Respiratory Society guidelines were used for assessment of the acceptability and repeatability criteria.

Results: The most common error in the first year of evaluation was forced vital capacity >6 seconds or a 1 second plateau. Acceptability and proper interpretation significantly improved after the course (p<0.05), but repeatability did not change significantly (p>0.05).

Conclusions: The results of this study show that the validity and quality of spirometric tests conducted in the studied company in Iran were unacceptable, but these improved significantly after the training intervention. The study demonstrated the lack of a systematic guideline for conducting spirometry and interpreting the results in the occupational setting in Iran, and emphasises the need for a nationwide programme to improve the quality of spirometry tests in this setting.