Impact of patient education and self-management on morbidity in asthmatics and patients with chronic obstructive pulmonary disease

The effect of patient education on morbidity in asthmatics and COPD patients has not previously been investigated in a single study. We randomized 78 asthmatics and 62 COPD patients after ordinary outpatient management. Intervention consisted of educational group sessions and individual sessions administered by a trained nurse and physiotherapist. A self-management plan was developed. The utilization of health resources and absenteeism from work was self-reported monthly. During the 12-month follow-up, approximately two (P= 0.001) and three (P= 0.001) times as many uneducated asthmatics and COPD patients, respectively, visited their general practitioner (GP) compared with educated. The mean reduction in GP consultations for the educated were 73% (P<0.001) and 85% (P<0.0001) for the asthma and COPD group, respectively, compared with uneducated. Fifty percent of uneducated asthmatics reported absenteeism from work compared with 24% of the educated (P = 0.06). The mean reduction in days offwork for the educated was 69% (P = 0.03), compared with uneducated. A positive correlation was observed between St George's Respiratory Questionnaire total score and number of GP visits for both the asthma and COPD group (P < 0.001). We conclude that patient education in asthmatics and COPD patients reduced the need for GP visits and kept a greater proportion of patients independent of their GP. Patient education among asthmatics also reduced the number of days off work and appeared to increase the proportion of patients not reporting absenteeism from work at all. Increasing number of GP visits was correlated with decreased health-related quality of life as measured by the SGRQ for both the asthmatics and the COPD patients.     

Cost-benefit and cost-effectiveness analysis of self-management in patients with COPD--a 1-year follow-up randomized,controlled trial

The aims were to explore the effects and health economic consequences of patient education in patients with COPD in a 12-month follow-up. Sixty-two patients with mild-to-moderate chronic obstructive pulmonary disease (COPD) were at our outpatient clinic randomly allocated to an intervention group or a control group. The intervention group participated in a 4-h schooling, followed by one-to-two individual nurse and physiotherapist consultations. Self-management was emphasized following a stepwise treatment plan. Effectiveness was expressed in terms of proportions in need of general practitioner (GP) consultations, patient satisfaction and utilization of rescue medication. Doctor visits, days off work, dispensed pharmaceuticals, hospital admissions, travel costs, educational and time costs were recorded. The control and intervention groups induced mean total costs of NOK 19900 and 10600 per patient, respectively. The results were robustto realistic changes in the assumptions upon which they were based. For every NOK put into patient education, there was a saving of 4.8. The NNE to make one patient independent of their GP was 1.7 (95% CI: 1.3--2.8) and associated with a concomitant saving of NOK 15 800. The corresponding NNE to make one person satisfied with their GP was 4.5 (95% CI: 2.9--10) and NOK 41900, respectively. A reduced need of 100 DDD of rescue medication was associated with a concomitant saving of NOK5600. We conclude that patient education of patients with COPD in a 12-month follow-up improved patient outcomes and reduced costs.     

How does patient education and self-management among asthmatics and patients with chronic obstructive pulmonary disease affect medication?

The effect of patient education on steroid inhaler compliance and rescue medication utilization in patients with asthma or chronic obstructive pulmonary disease (COPD) has not been previously investigated in a single study. We randomized 78 asthmatics and 62 patients with COPD after ordinary outpatient management. Intervention consisted of two 2-h group sessions and 1 to 2 individual sessions by a trained nurse and physiotherapist. A self-management plan was developed. We registered for 12 mo medication dispensed from pharmacies according to the Anatomical Therapeutic Chemical (ATC) classification index. Steroid inhaler compliance (SIC) was defined as (dispensed/prescribed) x 100 and being compliant as SIC > 75%. Among asthmatics 32% and 57% were compliant (p = 0.04) with a median (25th/75th percentiles) SIC of 55% (27/96) and 82% (44/127) (p = 0.08) in the control and intervention groups, respectively. Patient education did not seem to change SIC in the COPD group. Uneducated patients with COPD were dispensed double the amount of short-acting inhaled beta(2)-agonists compared with the educated group (p = 0.03). We conclude that patient education can change medication habits by reducing the amount of short-acting inhaled beta(2)-agonists being dispensed among patients with COPD. Educated asthmatics showed improved steroid inhaler compliance compared with the uneducated patients, whereas this seemed unaffected by education in the COPD group.     

Open access echocardiography has diagnostic yield similar to outpatient echocardiography and is highly rated by general practitioners and patients

BACKGROUND: Open access echocardiography is widely available to General Practitioners (GP). There is little data comparing the proportion of echocardiographic studies which are abnormal in open access series with that in hospital outpatient practice. This study compares the diagnostic yield from echocardiograms performed for similar indications by open access and hospital out patient requested groups and assesses the attitudes of GPs and patients to open access echocardiography. METHODS: The reports of 151 consecutive patients who had open access echocardiograms were analysed using predefined criteria for an abnormal study. The reports of 100 consecutive patients who had a new outpatient requested echocardiograms for similar indications were used as the control group. The attitudes of GPs and patients to the open access service were also assessed. RESULTS: Fifty seven percent of patients in the open access group and 51% in the hospital requested group had abnormal studies (p>0.05). 92% of GPs who responded to the questionnaire thought the report was easy to understand while 69% thought it led to a change in patient management. 74% said a clinic referral would have been made without this service and 79% preferred a management strategy to be included in the report. 90% of patients had been informed of the result by their GP. CONCLUSIONS: Open access echocardiography has a diagnostic yield similar to echocardiograms requested on new hospital outpatients in a district general hospital setting. GPs and patients report high levels of satisfaction with this service.     

The proportion of general practitioner referrals to a hospital Respiratory Medicine clinic suitable to be seen in a GPwSI Respiratory Clinic.

AIMS: The purpose of this study was to examine the proportion of general practitioner (GP) referrals to a hospital Respiratory Medicine clinic which might be suitable for a General Practitioner with a Special Interest (GPwSI) Respiratory Clinic. METHOD: All GP referral letters to the Respiratory Medicine Department of a teaching hospital, apart from urgent cancer referrals, were identified from two two-week periods. All patient and practice identifications were removed. Two GPs and one Consultant Respiratory Physician assessed each of the anonymised referral letters to determine the patient's suitability to be seen in a GPwSI Respiratory Clinic, assuming such a clinic had a predetermined range of investigative facilities. RESULTS: Out of 96 referrals covering a wide range of respiratory conditions apart from lung cancer, 22 (23%) were considered by all assessors to be suitable for a GPwSI clinic, and there was full agreement that 40 referrals (42%) were unsuitable. The other 34 referrals (35%) had varying degrees of agreement on suitability. The largest groups of patient referrals considered suitable for a GPwSI clinic were those with chronic obstructive pulmonary disease (COPD) or cough as the main presenting clinical problem. The commonest groups considered unsuitable were referrals of patients with an abnormal chest radiograph, haemoptysis, or possible interstitial lung disease. CONCLUSION: This small study has shown that at least a fifth of GP referrals to a hospital Respiratory Medicine clinic could be seen in a suitably resourced GPwSI clinic, with consequent reductions in hospital outpatient waiting lists and improved accessibility for patients. This finding will be of interest to potential commissioners of GPwSI services especially with the advent of Practice-based Commissioning.     

Quality of life assessment after patient education in a randomized controlled study on asthma and chronic obstructive pulmonary disease

The effect of patient education in patients with asthma and Chronic Obstructive Pulmonary Disease (COPD) on health-related quality of life (HRQoL) is not previously investigated using the St. George's Respiratory Questionnaire (SGRQ). We randomly allocated at our out-patient clinic 78 asthmatics and 62 patients with COPD to either a control or an intervention group. Intervention consisted of two 2-h group sessions and one to two individual sessions each by a nurse and a physiotherapist. A self-management plan was developed. Baseline quality of life assessment showed comparable scores independent of treatment groups among asthmatics and patients with COPD, but statistically significantly better scores (p < 0.05) for the educated asthma group after 12 mo compared with the control group. This aligned with the 12-mo SGRQ assessment, which revealed better symptoms, activity, impact, and total scores by 11 (p < 0.02), 15 (p < 0.01), 19 (p < 0.001), and 16 (p < 0.001) units, respectively. Patient education among asthmatics increased the FEV1 by a mean value of 6.1% (SD, 12) compared with the control group (p < 0.05). Education among patients with COPD did not indicate a significant increase in HRQoL as measured by the SGRQ or increased FEV1. We conclude that patient education increased HRQoL and FEV1 among asthmatics, but not among patients with COPD.     

Functional status and patient satisfaction a comparison of ischemic heart disease,obstructive lung disease,and diabetes mellitus

OBJECTIVE: To determine the extent to which chronic illness and disease severity affect patient satisfaction with their primary care provider in general internal medicine clinics. DESIGN: Cross-sectional mailed questionnaire study. SETTING: Primary care clinics at 7 Veterans Affairs medical centers. PATIENTS/PARTICIPANTS: Of 62,487 patients participating in the Ambulatory Care Quality Improvement Project, 35,383 (57%) returned an initial screening questionnaire and were subsequently sent a satisfaction questionnaire. Patients (N=21,689; 61%) who returned the Seattle Outpatient Satisfaction Survey (SOSQ) were included in the final analysis, representing 34% of the original sample. MEASUREMENTS AND MAIN RESULTS: The organizational score of the SOSQ measures satisfaction with health care services in the internal medicine clinic, and the humanistic scale measures patient satisfaction with the communication skills and humanistic qualities of the primary care physician. For ischemic heart disease (IHD), chronic obstructive pulmonary disease (COPD), and diabetes, patient ability to cope with their disease was more strongly associated with patient satisfaction than disease severity. Among IHD patients, improvement in ability to cope emotionally with their angina was associated with higher SOSQ organizational scores (standardized beta=0.18; P<.001) but self-reported physical limitation due to angina was not (beta=0.01; P=.65). Similarly, in COPD, improved ability to cope with dyspnea was associated with greater organizational scores (beta=0.11; P<.001) but physical function was not (beta=-0.03; P=.27). For diabetes, increased education was associated with improved organizational scores (beta=0.31; P<.001) but improvement in symptom burden was not (beta=0.03; P=.14). Similar results were seen with prediction of SOSQ humanistic scores. CONCLUSIONS: Patient education and ability to cope with chronic conditions are more strongly associated with satisfaction with their primary care provider than disease severity. Further improvements in patient education and self-management may lead to improved satisfaction and quality of care.     

Effect of spanish interpretation method on patient satisfaction in an urban walk-in clinic

OBJECTIVE: To examine the effect of Spanish interpretation method on satisfaction with care. DESIGN: Self-administered post-visit questionnaire. SETTING: Urban, university-affiliated walk-in clinic. PARTICIPANTS: Adult, English- and Spanish-speaking patients presenting for acute care of non-emergent medical problems. MEASUREMENTS AND MAIN RESULTS: Satisfaction with overall clinic visit and with 7 provider characteristics was evaluated by multiple logistic regression, controlling for age, gender, ethnicity, education, insurance status, having a routine source of medical care, and baseline health. "Language-concordant" patients, defined as Spanish-speaking patients seen by Spanish-speaking providers and English-speaking patients, and patients using AT&T telephone interpreters reported identical overall visit satisfaction (77%; P = .57), while those using family or ad hoc interpreters were significantly less satisfied (54% and 49%; P < .01 and P = .007, respectively). AT&T interpreter use and language concordance also yielded similar satisfaction rates for provider characteristics (P > .2 for all values). Compared to language-concordant patients, patients who had family members interpret were less satisfied with provider listening (62% vs 85%; P = .003), discussion of sensitive issues (60% vs 76%; P = .02), and manner (62% vs 89%; P = .005). Patients who used ad hoc interpreters were less satisfied with provider skills (60% vs 83%; P = .02), manner (71% vs 89%; P = .02), listening (54% vs 85%; P = .002), explanations (57% vs 84%; P = .02), answers (57% vs 84%; P = .05), and support (63% vs 84%; P = .02). CONCLUSIONS: Spanish-speaking patients using AT&T telephone interpretation are as satisfied with care as those seeing language-concordant providers, while patients using family or ad hoc interpreters are less satisfied. Clinics serving a large population of Spanish-speaking patients can enhance patient satisfaction by avoiding the use of untrained interpreters, such as family or ad hoc interpreters.     

Patients at the outpatient rheumatology clinic: do they really need to be there?

BACKGROUND: The workload at many outpatient clinics within the Dutch health care system has been growing relentlessly, resulting in unacceptable waiting lists and reduced accessibility. Assessing streams of patients and introducing a method of accelerated referral of patients back to the general practitioner (GP) under specialist guidance could help to alleviate these problems. METHODS: Seventeen GPs collaborated with rheumatologists during a 2-year period in a 'joint consultation' model in which GPs and rheumatologists discussed patients together. All patient charts belonging to patients who had been referred to the outpatient clinic by these 17 GPs were identified. Rheumatologists assessed whether or not these patients could be referred back to the participating GPs under the guidance of the specialist in the joint consultation model. RESULTS: Of 276 eligible patients, 121 were discharged from the outpatient clinic. Eighty-seven patients required specialist follow-up, 22 patients refused to participate, and six patients were not entered into the study by the rheumatologist. Some 21 patients eventually entered the study, 18 of whom were referred back to the GP. CONCLUSION: The role of joint consultation appears to be limited. Improving the referral behavior of GPs should take precedence over transferring follow-up from the outpatient clinic to the primary care level.     

Prevalence of gastroesophageal reflux disease in patients with asthma and chronic obstructive pulmonary disease

Background and Aim: It is speculated that the prevalence of gastroesophageal reflux disease (GERD) might increase with asthma or chronic obstructive pulmonary disease (COPD). The aim of the present study was to evaluate the prevalence of GERD in patients with asthma and COPD in an area representative of developing countries. Methods: A validated GERD questionnaire was conducted face‐to‐face with 308 consecutive asthma (240 women) and 133 COPD (35 women) patients in the tertiary referral pulmonary outpatient clinic, and 694 controls from the research area. Detailed histories of patients and pulmonary function tests were also recorded. Results: The prevalence of GERD (heartburn/regurgitation once a week or more) was 25.4%, 17.0%, 19.4% and occasional symptoms (less than weekly) were 21.2%, 16.3% and 27.0% of patients with asthma, COPD and controls, respectively. The prevalence was higher in the asthma group compared with the controls and the COPD group. No significant difference was found between the COPD group and the controls. Heartburn started following pulmonary disease in 24.1% of the asthma group, and 26.4% of the COPD group. The majority of additional symptoms were significantly higher in asthmatics compared with the controls. No difference was found in the consumption of pulmonary medications in asthmatic patients in groups with different symptom frequency. Heartburn was increased 13.8% by the consumption of inhaler medications. Conclusions: These results implicate that the prevalence of GERD in asthma and COPD are lower than in published reports in a tertiary referral center. These differences might be related to the characteristics of developing countries, increased consumption of powerful medications in GERD and pulmonary diseases, or methodological flaws in earlier studies.     

Joint consultation of general practitioner and rheumatologist: does it matter?

OBJECTIVE: To assess the effects of joint consultation on referral behaviour of general practitioners (GPs) in a prospective cohort study. METHODS: All patients with rheumatological complaints that 17 participating GPs, from the area of the University Hospital Maastricht, wanted to refer during a two year inclusion period (n=166) were eligible for inclusion. These patients were either referred to the outpatient clinic, or presented at a joint consultation held every six weeks at the practice of the GP, where groups of three GPs presented their patients to a visiting, consulting rheumatologist. The number of patients referred by each GP a year at the end of the trial, comparing participating and non-participating GPs, was the main outcome measure. RESULTS: During two years of inclusion, the 17 participating GPs presented 166 patients. The number of patients referred by each GP a year decreased for the participating GPs by 62% at the end of the whole study. By contrast, non-participating GPs maintained the same rate of referral. The range of diagnoses remained proportionally the same throughout the study, with the exception of fibromyalgia. The referral rate of this diagnosis decreased significantly (p=0.001). CONCLUSIONS: Joint consultation seems to be a good strategy in influencing the referral behaviour of GPs in the area of rheumatology. The decrease in referral is substantial and can subsequently lead to a reduction of waiting lists.     

The functional impact of an individualized, graded, outpatient pulmonary rehabilitation in end-stage chronic obstructive pulmonary disease

OBJECTIVE: To evaluate the functional impact of an individualized outpatient pulmonary rehabilitation program in end-stage chronic obstructive pulmonary disease (COPD). METHODS: Patients with end-stage COPD were admitted into a 6-week comprehensive outpatient pulmonary rehabilitation program that was "packaged" for each patient. We compared spirometric parameters, exercise tolerance, level of breathlessness, and intensity of work before and after rehabilitation. RESULTS: Of 45 eligible patients, only 14 consented to participate in the study. All 14 patients had forced expiratory volume in 1 second <35% of predicted, and 10 patients (72%) had a 6-minute walk test <180 m. The level of breathlessness was between 7 (moderate to severely breathless) and 10 (maximally breathless) on the Visual Analogue Scale in all patients. After the program, there was significant improvement in the FEV 1 P = 0.04), forced vital capacity P = 0.0045), 6-minute walk test P = 0.00047), and shuttle-walk test (9 of 14 patients). All patients had some improvement in level of dyspnea. CONCLUSIONS: Individualized outpatient pulmonary rehabilitation in end-stage COPD can produce a measurable improvement in spirometry and exercise tolerance with a favorable impact on the level of physical activity.     

Muscle strength and exercise kinetics in COPD patients with a normal fat-free mass index are comparable to control subjects

STUDY OBJECTIVE: This study was designed to investigate the extent of clinical muscle dysfunction in stable patients with COPD who were attending an out-patient pulmonary clinic compared with that of age-matched control subjects without COPD. Design and subjects: Respiratory muscle and hand grip strength, steady-state O(2) kinetics, and body composition were measured in 32 patients with COPD (19 women) [mean (+/- SD) FEV(1), 38 +/- 11% predicted] and 36 age-matched control subjects (13 women). RESULTS: Measurements of handgrip force (mean, 97 +/- 32% vs 106 +/- 26% predicted, respectively), maximal expiratory pressure (mean, 57 +/- 33% vs 61 +/- 22% predicted, respectively), steady-state O(2) kinetics (mean tau, 72 +/- 34 s vs 78 +/- 37 s, respectively) and steady-state CO(2) kinetics (mean tau, 77 +/- 38 s vs 65 +/- 32 s, respectively) at submaximal exercise were similar in patients and control subjects. All the subjects, except for one female COPD patient, had a normal fat-free mass index (FFMI), although on average the FFMI was lower in male patients (19.8 +/- 2.8) than in male control subjects (23.0 +/- 2.8; p < 0.01). CONCLUSIONS: In patients with COPD who were attending a regular outpatient pulmonary clinic, there was no evidence of reduced upper extremity and expiratory muscle strength or prolonged O(2) and CO(2) kinetics during isowork submaximal cardiopulmonary exercise compared to healthy, age-matched control subjects. Also, a normal body composition was found in nearly all COPD patients. This argues against the existence of a clinically significant systemic myopathy in most stable patients with severe COPD and normal FFMI.     

Comparison of clinical management of young and elderly asthmatics by respiratory specialists and general practitioners

Background: Asthmatic death in the elderly is a serious problem worldwide. Differences in clinical skill between respiratory specialists (RS) and general practitioners (GP) are important in asthma control. The aim of this study was to compare asthma management between RS and GP. Methods: A cross-sectional survey was carried out in Shimane, Japan, in February 2009 using a questionnaire about patient background, treatment, asthma control test (ACT) and adherence to treatment. We secured the cooperation of 48 clinics (39 private clinics and 9 general hospitals). Asthmatics were divided into the elderly and young groups, and also into the RS and GP groups. Results: Clinical data of 779 patients were available for analysis. Elderly patients constituted 464 (RS group: 192, GP group: 272), while those of the young group were 315 (RS group: 207, GP group: 108). RS prescribed inhaled corticosteroids (ICSs) to their elderly and young patients more than GP. The total ACT score was higher in young RS group than in young GP group, but no such difference was noted in the elderly. Despite more asthma-related symptoms, the ACT showed that elderly GP asthmatics used fewer rescue inhalers than elderly RS. Self-assessment was higher in elderly GP than elderly RS asthmatics. Adherence to therapy was better in elderly patients than young patients. Conclusions: Elderly asthmatics treated by GPs underestimated the severity of their asthma and asthmatics seen by GPs were undertreated. The results stress the need to engage patients in educational activities, to adhere to guidelines, and to improve the coordination between GP and RS.     

Review of the function of a telephone helpline in the treatment of outpatients with rheumatoid arthritis

OBJECTIVES: To examine the role, acceptability, and cost effectiveness of a telephone helpline organised and run by specialist nurses in a district general hospital outpatient rheumatology department. MATERIAL AND METHODS: Patients accessed the telephone helpline by leaving a taped message on an answer phone with a 24 hour response time. Assessment included an audit of the nature and outcome of helpline calls, patient satisfaction with the helpline, and a health economic analysis of the helpline operation. A postal questionnaire was used to assess patient satisfaction; this was sent to the 87 patients who called the helpline during one month, and overall satisfaction with the helpline was assessed. The nature and outcome of all calls was analysed retrospectively using a helpline record book for February and October of one year and February of the following year. From the results of the retrospective analysis and an estimate of the number of general practitioner consultations avoided by provision of the helpline, the cost effectiveness of the helpline was calculated. RESULTS: Of those returning questionnaires, 61/63 (97%) were satisfied with the response time, 63/63 (100%) with the courtesy, and 60/63 (95%) felt that their questions were answered directly and to their satisfaction in 62 (98%) of cases. Had the helpline not been available, 38/63 (60%) patients would have made an appointment with their GP. When these figures were extrapolated to an annual estimation, a basic cost analysis showed that the helpline produced a cost saving to the NHS, largely as a result of GP consultations avoided. CONCLUSION: Clinical advice and support can be provided by a rheumatology helpline set up as an adjunct to a standard outpatient service. The results of a postal questionnaire suggested more than 95% satisfaction with all aspects of the helpline service and that 99% of callers would call the helpline again. The provision of the helpline service contributes to the quality of care provided by an outpatient department and provides benefit to the NHS.     

Diagnosis and Management of Chronic Obstructive Pulmonary Disease (COPD) in a Primary Care Clinic

ABSTRACT

Chronic Obstructive pulmonary disease (COPD) is an important cause of morbidity and mortality in the United States and internationally. The purpose of this study was to describe spirometry use in the diagnosis of COPD and to evaluate the management of COPD occurring in a primary care clinic. Methods: Two hundred patients with a diagnosis of COPD attending a university-based family medicine clinic were randomly chosen for a retrospective medical record review. Pulmonary function testing, provision of smoking cessation advice and pharmacological management were compared to the recommendations of the Global Initiative for Chronic Obstructive Lung Disease. Results: Mean age was 65.4 years, 48% were male and 72% were Caucasian. Overall, 58.5% (n = 117) of patients had pulmonary function testing, with 60.7% acknowledged in the outpatient record; 55% (n = 110) were receiving medications in combinations that are recommended; and 40% of patients were receiving stage appropriate medications. 67.8% of current smokers were offered smoking cessation advice or treatment. Conclusions: Overall there was low use of recommended medication combinations and stage appropriate treatment, with better observance of diagnostic and risk factor reduction guidelines. In order to improve COPD care for patients, physicians need education about the recommended stepwise treatment options and office systems that promote integration of pulmonary function testing findings into care.     

The cost of moderate and severe COPD exacerbations to the Canadian healthcare system

BACKGROUND: The cost of exacerbations in chronic obstructive pulmonary disease (COPD) has not been well studied. The aim of this study was to identify and quantify the (average) cost of moderate and severe exacerbations (ME and SE, respectively) from a Canadian perspective. METHODS: Resources used during ME and SE were identified in a year long prospective, observational study (Resource Utilization Study In COPD (RUSIC)). The units of analysis were ME and SE. Unit costs (2006$CAN), based on provincial, hospital and published sources, were applied to resources. The overall cost per ME and SE were calculated. The population burden of exacerbations was also calculated. RESULTS: Among study participants (N=609, aged 68.6+/-9.4 years, 58.3% male) there were 790 exacerbations: 639 (80.9%) MEs and 151 (19.1%) SEs. Of the 790 exacerbations, 618 (78.2%), 245 (31.0%) and 151 (19.1%) included a visit to an outpatient clinic, emergency department (ED) or hospital, respectively. For ME, 85.9% and 13.1% involved visits to GPs and respirologists, respectively. Pharmacologic treatment changes in the outpatient setting involved antibiotics (63.1%) and corticosteroids (34.7%). The overall mean costs for outpatient and ED services for MEs were $126 (N=574) and $515 (N=105), respectively. The average overall cost of a ME was $641. For SEs, the average hospital stay was 10.0 days. The overall mean costs of outpatient, ED and hospitalization services for SE were $114 (N=44), $774 (N=140) and $8669 (N=151), respectively. The average overall cost of a SE was $9557. CONCLUSION: The economic burden associated with MEs and especially SEs, in Canada, is considerable and likely has a substantial impact on healthcare costs. The overall burden of exacerbations has been estimated in the range of $646 million to $736 million per annum.     

支气管哮喘和慢性阻塞性肺疾病患者诱导痰中基质金属蛋白酶及其抑制剂与气道炎症及气流受限

目的探讨支气管哮喘（简称哮喘）和慢性阻塞性肺疾病（COPD）患者诱导痰中基质金属蛋白酶9（MMP-9）和基质金属蛋白酶抑制剂1（TIMP-1）的水平及其与炎性细胞数、肺功能的关系。方法分别选择14例缓解期哮喘患者（哮喘组）、12例稳定期COPD患者（COPD组）和10名健康对照者（健康对照组）进行肺功能测定和用诱导痰检查方法对痰炎性细胞进行分类计数，并用酶联免疫吸附试验（ELISA）法测定诱导痰上清液中自细胞介素4（IL-4）、MMP-9和TIMP-1浓度。结果哮喘组患者诱导痰中嗜酸粒细胞、中性粒细胞分别为0．181±0．067、0．30±0．07，健康对照组为0．007±0．005、0．26±0．06，COPD组为0．042±0．017、0．50±0．10，3组细胞间比较差异有统计学意义（F值分别为4．32、4．13，P均〈0．05）。哮喘组、COPD组、健康对照组间诱导痰中IL-4浓度分别为（19±7）×10^-3／L、（14±6）×10^-3g／L、（11±4）×10^-3g／L，3组诱导痰中IL-4浓度比较差异无统计学意义（F=1．56，P均〉0．05），且分别与嗜酸粒细胞、中性粒细胞和第一秒用力呼气容积占预计值百分比（FEV1占预计值％）无相关（r分别为0．33、0．11、0．19、0．25、0．39、0．40、0．21、0．35、0．17，P均〉0．05）。哮喘组和COPD组诱导痰中MMP-9、TIMP-1浓度分别为（15．9±6．0）g／L、（13．4±5．1）g／L、（19．8±8．5）g／L、（16．7±7．6）g／L，健康对照组分别为（1．8±1．1）g／L、（1．3±0．9）g／L，两组MMP-9、TIMP-1浓度比较差异有统计学意义（F值分别为2．99、4．22，P均〈0．05）。哮喘组MMP-9浓度与嗜酸粒细胞呈正相关（r=0．71，P〈0．05）；COPD组MMP-9浓度与中性粒细胞呈正相关（r=0．59，P〈0．05），但与FEV。占预计值％和第一秒用力呼气容秽用力肺活量（FEV1／FVC）无相关（r分别为0．22、0．16、0．25、0．30，P均〉0．05）。哮喘组和COPD组TIMP．1浓度均与嗜酸粒细胞和中性粒细胞无相关（r分别为0．27、0．31、0．20、0．35，P均〉0．05），但与FEV。占预计值％呈负相关（r分别为-0．58、-0．62，P均〈0．05）。哮喘组和COPD组诱导痰中MMP-9／TIMP-1比值分别为0．8±0．7、0．8±0．6，两组比较差异无统计学意义（F=1．78，P〉0．05），但与健康对照组（1．5±0．6）比较差异有统计学意义（F=3．70，P〈0．05），且与FEV1占预计值％呈正相关（r分别为0．56、0．61，P均〈0．05）。结论哮喘组和COPD组患者诱导痰中MMP-9／TIMP-1比值的失衡与气道炎症和气流受限有关，这种失衡在哮喘和COPD细胞外基质的重塑和气流受限的发病机制中发挥重要作用。     

Chronic obstructive pulmonary disease is missed in asthmatics in specialty care in Trinidad, West Indies.

SETTING: Underdiagnosis of chronic obstructive pulmonary disease (COPD) in asthmatics attending specialty care in Trinidad, West Indies. OBJECTIVE: To determine the prevalence of COPD in diagnosed asthmatics receiving specialty respiratory care. DESIGN: In a cross-sectional study, 258 asthmatics were screened for lung function measures to examine forced expiratory volume after 1 second (FEV1), forced vital capacity (FVC) and post-bronchodilator FEV1/FVC (COPD was defined as FEV1/FVC < 70%). RESULTS: Of 165 patients evaluated (response rate 64.0%), 53 (32.1%, 95%CI 25.0-39.2) had a study diagnosis of COPD and a mean FEV1/FVC of 60.12 +/- 1.2. Proportionally, more males had COPD (50.9%) than asthma (24.1%, P < 0.001). Patients with COPD were 10 years older than asthmatics (P < 0.001). Persons with asthma who smoked were more likely to have COPD (56.0%) (OR 3.26, 95%CI 1.36-7.80, P = 0.006). In both sexes, FEV1/FVC was lower among older people (P < 0.001), with a greater effect (OR 2.75, 95%CI 1.00-7.56, P < 0.01) seen among men in this cross-sectional study. CONCLUSIONS: One third of diagnosed asthmatics in specialty care also have COPD. Lung function was lower among older persons. Early spirometric evaluation of elderly asthmatics who smoke can determine the presence of COPD and facilitate appropriate management.