THE SILENT EPIDEMIC of COPD: HOW IT HITS FAMILY PRACTICE

潜在流行性慢阻肺对家庭医生的困扰PROF. CHRIS VAN WEEL

UMC NIJMEGEN, THE NETHERLANDS

professor Chris van Weel

Epidemiology: 流行病学 from population to practice

从居民到医生• COPD as the example-study 慢阻肺作为研究范例• Practice level: individual advice and therapy• Role of family physician 家庭医生的作用

– Organize individual care, population perspective

对居民有组织的个体化照顾• Data from the Netherlands 荷兰的数据

– Encouragement to pursue Chinese data

– Critical for leadership

实际水平：个体化指导和治疗

对中国人的追踪研究数据

对领导工作的评价

professor Chris van Weel

COPDIn family practice家庭医疗中的慢阻肺

• Incidence* 发病率 2 – 3 / 1,000 • Prevalentie* 患病率 22 / 1,000• ‘Average’ family practice: 每个家庭医生平均患者

– 55 under treatment 治疗中– 6 - 7 new cases yearly 每年新病例* Data Continous Morbidity Registration, Department of Family Medicine, Nijmegen

根据家庭医学部持续登记的患病率

professor Chris van Weel

Trends1996 – 2050*1996-2050 的趋势

010

2030

405060

7080

90100

1996 2020 2035 2050

HFcataractCOPD

* Data Continuous Morbidity Registration, Department of Family Practice,

Nijmegen 根据家庭医学部持续登记的患病率

professor Chris van Weel

Only ‘diagnosed cases’

• Dimca Study: undiagnosed COPD

• 10 Family practices Nijmegen, 1992

• Questionnaires and spirometry

• 1159 adults without known COPD, asthma

• How to make a difference?

仅“已诊断的病例”

漏诊的慢阻肺

1992 年 10 个家庭医生的材料

问卷调查及肺活量测定

1159 例没有已知慢阻肺和哮喘的成年人

如何鉴别？

professor Chris van Weel

1977 1992

Prevalence COPD and AsthmaIn practice population 居民中慢阻肺和哮喘的患病率

(Tirimanna et al Br J Gen Pract 1996;46:277-282)

professor Chris van Weel

Underdiagnosis* 漏诊

• Substantial: 7% population signs/symptoms

• Increased prevalence 1977 - 1992

• Diagnostic uncertainty

– mainly mild disease (Gold stages 1, 2)

• Effectiveness early intervention unclear

* Tirimanna et al Br J Gen Pract 1996;46:277-282

实际数：有症状 / 体征者 7%1977-1992 年患病率增加

诊断不肯定

早期干预效果不肯定

主要是轻病例(Gold 1 、 2 期 )-

professor Chris van Weel

Determinants underdiagnosis漏诊的决定因素

• PHYSICIAN 医生方面

– Knowledge 知识– Skills 技能– Implications 暗示– expectation: 期望值：

• label/stigma 标记 / 担心• smoking cessation 戒烟

• PATIENT 病人方面

– tolerate symptoms 能忍受– dislike medication 不想吃药– anxiety stigma 焦虑担心– ‘know’ FP advice: 知道医生要劝：

• smoking cessation 戒烟

professor Chris van Weel

5 years DIMCA: Gold Class & Functional Status

DIMCA5 年 : Gold 分级及功能状况COOP-WONCA scores after 5 years

T=0

Physical

fitness

95% CI Daily

activities

95% CI

Not classified 2.29 2.17-2.41 1.67 1.56-1.78

GOLD 0 2.50 2.06-2.94 1.93 1.31-2.55

GOLD 1 2.07 1.54-2.60 1.07 0.92-1.23

GOLD 2 2.85 2.20-3.49 2.38 1.58-3.19

5 年后 COOP-WONCA 量表评分

体能 日常活动

professor Chris van Weel

Coop/Wonca ChartsCOOP/WONCA 量表

Daily Actvities 日常活动Physical Fitness 体能

professor Chris van Weel

professor Chris van Weel

5 years DIMCA: Gold Class & Functional Status

DIMCA5 年 : Gold 分级及功能状况COOP-WONCA scores after 5 years

T=0

Physical

fitness

95% CI Daily

activities

95% CI

Not classified 2.29 2.17-2.41 1.67 1.56-1.78

GOLD 0 2.50 2.06-2.94 1.93 1.31-2.55

GOLD 1 2.07 1.54-2.60 1.07 0.92-1.23

GOLD 2 2.85 2.20-3.49 2.38 1.58-3.19

体能 日常活动

professor Chris van Weel

Effectiveness Early Intervention (DIMCA) 早期干预的作用

• Early treatment*: 早期治疗：– Improves quality of life & functioning 改善生活质量及功能– Reduces exacerbations 减少恶化– No effect lungfunction decline 肺功能减低无作用

No effect mild persistent symptoms 轻度持续性症状无作用• No case for screening 无供筛查病例 • No alternative primary prevention: smoking, open fires

cessation 无可替代的一级预防：戒烟和明火* van den boom et al Prev Med, 30, 302-308

professor Chris van Weel

Conclusion 结论• COPD important problem practice population

慢阻肺是居民中的重要问题• Diagnosis and treatment 诊断和治疗

– Make a difference 区别对待• But smoking cessation

——Key to success 戒烟是胜利的关键 • Family medicine leadership 家庭医学主导

– address population needs 致力于公众需求– priority to what counts 优先解决遇到的问题