Primary Care Respiratory Journal最新文献

Background: In practice it is logical that inhalers are prescribed only after patients have received training and demonstrated their ability to use the device. However, many patients are unable to use their pressurised metered-dose inhaler devices (pMDIs) correctly. We assessed the relationship between asthma control and patients' ability to use their prescribed pMDIs.

Methods: Evaluation of 3,981 (46% male) primary care asthma patient reviews, which included inhaler technique and asthma control, by specialist nurses in primary care in 2009. The paper focuses on people currently prescribed pMDI devices.

Results: Accurate data on reliever and preventer inhaler prescriptions were available for 3,686 and 2,887 patients, respectively. In patients prescribed reliever inhalers, 2,375 (64%) and 525 (14%) were on pMDI alone or pMDI plus spacer, respectively. For those prescribed preventers, 1,976 (68%) and 171 (6%) were using a pMDI without and with a spacer, respectively. Asthma was controlled in 50% of patients reviewed. The majority of patients (60% of 3,686) were using reliever pMDIs, 13% with spacers. Incorrect pMDI use was associated with poor asthma control (p<0.0001) and more short burst systemic steroid prescriptions in the last year (p=0.038). Of patients using beclometasone (the most frequently prescribed preventer drug in our sample), significantly more of those using a breath-actuated pMDI device (p<0.0001) and a spacer (p<0.0001) were controlled compared with those on pMDIs alone.

Conclusions: Patients who are able to use pMDIs correctly have better asthma control as defined by the GINA strategy document. Beclometasone via a spacer or breath-actuated device resulted in better asthma control than via a pMDI alone. Patients prescribed pMDIs should be carefully instructed in technique and have their ability to use these devices tested; those unable to use the device should be prescribed a spacer or an alternative device such as one that is breath-actuated.

Background: There are concerns about the reporting quality of asthma trials.

Aims: To describe the reporting of contemporary asthma trials and to identify factors associated with better reporting quality.

Methods: Two reviewers independently searched MEDLINE for randomised controlled trials (RCTs) of asthma published between January 2010 and July 2012 in leading generalist and specialist journals. We calculated the proportion of trials that adequately reported each Consolidated Standards of Reporting Trials (CONSORT) checklist item and an overall quality score for each trial. Factors associated with better reporting quality were investigated.

Results: Thirty-five RCTs satisfied our eligibility criteria. Four trials adequately reported <50% of the items, 15 adequately reported 50-60% of items, and 16 adequately reported >60% of items. Seventeen of the 38 CONSORT items were consistently well reported in more than two-thirds of the articles. In contrast, nine items were poorly reported in more than half the trials - namely, identification as a randomised trial in the title (40.0%), an adequate structured summary/abstract (48.6%), details of eligibility criteria (34.3%), recruitment (48.6%), randomisation procedures (22.9%), intervention (38.5%), harms (34.3%), the funding source (45.7%), and access to the full trial protocol (17.1%). Studies led by teams in high-income country settings were associated with better quality of reporting (relative risk=1.33, 95% CI 1.09 to 1.64).

Conclusions: The quality of reporting in contemporary asthma literature remains suboptimal. We have identified important areas in which reporting quality needs to be improved.

Background: Smoking cessation advice is important for reducing the worldwide burden of disease resulting from tobacco smoking. Appropriate risk communication formats improve the success of counselling interventions in primary care.

Aims: To test the feasibility and acceptance of a smoking cessation counselling tool with different cardiovascular risk communication formats including graphs, in comparison with the International Primary Care Respiratory Group (IPCRG) 'quit smoking assistance' tool.

Methods: GPs were randomised into an intervention group (using our communication tool in addition to the IPCRG sheet) and a control group (using the IPCRG sheet only). We asked participants for socioeconomic data, smoking patterns, understanding of information, motivation, acceptance and feasibility, and measured the duration and frequency of counselling sessions.

Results: Twenty-five GPs performed 2.8 counselling sessions per month in the intervention group and 1.7 in the control group (p=0.3) with 114 patients. The median duration of a session was 10 mins (control group 11 mins, p=0.09 for difference). Median patients' motivation for smoking cessation was 7 on a 10-point visual analogue scale with no significant difference before and after the intervention (p=0.2) or between groups (p=0.73 before and p=0.15 after the intervention). Median patients' ratings of motivation, selfconfidence, understanding of information, and satisfaction with the counselling were 3-5 on a 5-point Likert scale, similar to GPs' ratings of acceptance and feasibility, with no significant difference between groups.

Conclusions: Among Swiss GPs and patients, both our innovative communication tool and the IPCRG tool were well accepted and both merit further dissemination and application in research.

Worsening breathless in a patient with severe chronic obstructive pulmonary disease (COPD) is a common diagnostic and management challenge in primary care. A systematic approach to history-taking and examination combined with targeted investigation of pulmonary, cardiovascular, thromboembolic and systemic causes is essential if co-morbidities are to be identified and managed. Distinguishing between heart failure and COPD is a particular challenge as symptoms and signs overlap. In low and middle income countries additional priorities are the detection of infections such as tuberculosis and human immunodeficiency virus (HIV). Clinicians need to be alert to the possibility of atypical presentations (such as pain-free variants of angina) and less common conditions (including chronic thromboembolic pulmonary hypertension) in order not to overlook important potentially treatable conditions.

Background: Previous studies have identified a discrepancy between patient perception of asthma control and real-world symptoms; despite several hypotheses, the reasons remain unclear.

Aims: To explore patients' experiences of asthma symptoms and disease management and their educational needs in the UK; to assess recent progress in asthma control and management.

Methods: A quantitative questionnaire-based online survey of UK patients aged >18 years with self-reported asthma.

Results: Of the 1,083 individuals (55% female, 49% aged >55 years) who completed the survey, 79% described their asthma control as 'good' or 'very good'. Despite this, in the previous 2 years, 65% had experienced 'frequent' day-time symptoms, 37% had 'frequent' night-time symptoms, and 25% had used oral steroids for asthma; 41% of those prescribed a reliever inhaler used it >1 a day. Overall, 76% had a 'good' or 'very good' relationship with their healthcare professional (HCP); 32% had not attended regular asthma reviews and only 12% were using a personal asthma action plan. Moreover, 70% of respondents felt that they had the 'main responsibility' for managing their asthma; 29% believed this responsibility to be shared with their HCP.

Conclusions: This survey indicates a continuing discrepancy between patient perception of asthma control and real-world symptoms, with little change from previous studies. Many patients accept symptoms as the norm. The diversity among respondents' attitudes demonstrates a need to help patients change some of their beliefs and understanding about asthma, and to improve asthma management with better education about the understanding of control for patients and HCPs.

Background: In patients with moderate to severe chronic obstructive pulmonary disease (COPD) the six-minute walk distance reflects the functional exercise level for daily physical activity. It is unknown if this also applies to patients with mild to moderate COPD in primary care.

Aims: To assess the relationship between functional exercise capacity and physical activity in patients with mild to moderate COPD.

Methods: A cross-sectional study was performed in 51 patients with mild to moderate COPD in primary care. Functional exercise capacity was assessed by the six-minute walk test and physical activity was measured with an accelerometer-based activity monitor.

Results: Functional exercise capacity was close to normal values. However, the daily physical activity of the patients could be classified as 'sedentary' and 'low active'. No significant correlations were observed between six-minute walk distance (% predicted) and any of the physical activity variables (steps per day, movement intensity during walking, total active time, total walking time, physical activity level, and time spent in moderate physical activity).

Conclusions: A discrepancy was found between functional exercise capacity and daily physical activity in patients with mild to moderate COPD recruited and assessed in primary care. We conclude that these variables represent two different concepts. Our results reinforce the importance of measuring daily physical activity in order to fine-tune treatment (i.e. focusing on enhancement of exercise capacity or behavioural change, or both).

Background: Community-acquired pneumonia (CAP) is an important cause of hospital admission and death, but the extent of the problem of CAP at the primary healthcare level is largely unknown.

Aims: To investigate the contribution of general practitioners (GPs) to the management of patients with CAP in the Netherlands.

Methods: The study population consisted of all people enlisted in a GP network. We obtained information on CAP episodes from GP electronic records (using ICPC code R81) during the years 2002-2009. CAP registrations were also obtained from national hospital discharge data (ICD-9 codes) and cause of death statistics (ICD-10 codes). The three registration systems were linked at the individual level. We used descriptive analyses to estimate the annual number of CAP episodes (i.e. defined as a CAP diagnosis within 30 days).

Results: From 2002 to 2009 the mean annual size of the study population was 395,039. For this population, 3,700 (0.9%) CAP episodes per year were registered in at least one of the registration systems, 2,933 (79%) of which were in the GP system only. Recovery within 30 days occurred on average in 95% (2,791/2,933) of the CAP episodes annually registered by a GP, while 2.3% (67/2,933) of patients with a GP-registered CAP episode were admitted to hospital within 30 days and 1% (26/2,933) had a fatal outcome within 30 days.

Conclusions: The vast majority of CAP episodes registered in the Netherlands are managed successfully at the GP level without hospitalisation.