症状和呼出一氧化氮分数驱动的哮喘控制策略：初级保健中的一项集群随机试验。
Symptom- and fraction of exhaled nitric oxide-driven strategies for asthma control: A cluster-randomized trial in primary care.
机构信息
Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands; Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands.
Department of General Practice, Academic Medical Center, Amsterdam, The Netherlands.
出版信息
J Allergy Clin Immunol. 2015 Mar;135(3):682-8.e11. doi: 10.1016/j.jaci.2014.07.016. Epub 2014 Aug 28.
BACKGROUND
Aiming at partly controlled asthma (PCa) instead of controlled asthma (Ca) might decrease asthma medication use. Biomarkers, such as the fraction of exhaled nitric oxide (Feno), allow further tailoring of treatment.
OBJECTIVE
We sought to assess the cost-effectiveness and clinical effectiveness of pursuing PCa, Ca, or Feno-driven controlled asthma (FCa).
METHODS
In a nonblind, pragmatic, cluster-randomized trial in primary care, adults (18-50 years of age) with a doctor's diagnosis of asthma who were prescribed inhaled corticosteroids were allocated to one of 3 treatment strategies: (1) aiming at PCa (Asthma Control Questionnaire [ACQ] score <1.50); (2) aiming at Ca (ACQ score <0.75); and (3) aiming at FCa (ACQ score <0.75 and Feno value <25 ppb). During 12 months' follow-up, treatment was adjusted every 3 months by using an online decision support tool. Outcomes were incremental cost per quality-adjusted life year gained, asthma control (ACQ score), quality of life (Asthma Quality of Life Questionnaire score), asthma medication use, and severe exacerbation rate.
RESULTS
Six hundred eleven participants were allocated to the PCa (n = 219), Ca (n = 203), or FCa (n = 189) strategies. The FCa strategy improved asthma control compared with the PCa strategy (P < .02). There were no differences in quality of life (P ≥ .36). Asthma medication use was significantly lower for the PCa and FCa strategies compared with the Ca strategy (medication costs: PCa, $452; Ca, $551; and FCa, $456; P ≤ .04). The FCa strategy had the highest probability of cost-effectiveness at a willingness to pay of $50,000/quality-adjusted life year (86%; PCa, 2%; Ca, 12%). There were no differences in severe exacerbation rate.
CONCLUSION
A symptom- plus Feno-driven strategy reduces asthma medication use while sustaining asthma control and quality of life and is the preferred strategy for adult asthmatic patients in primary care.
背景
针对部分控制的哮喘（PCa）而不是控制的哮喘（Ca）可能会减少哮喘药物的使用。生物标志物，如呼气一氧化氮（Feno）的分数，允许进一步调整治疗。
目的
我们旨在评估追求 PCa、Ca 或 Feno 驱动的控制哮喘（FCa）的成本效益和临床效果。
方法
在初级保健中的非盲、实用、集群随机试验中，年龄在 18-50 岁之间、经医生诊断患有哮喘且已开吸入皮质类固醇的成年人被分配到以下 3 种治疗策略之一：（1）针对 PCa（哮喘控制问卷[ACQ]评分<1.50）；（2）针对 Ca（ACQ 评分<0.75）；和（3）针对 FCa（ACQ 评分<0.75 和 Feno 值<25 ppb）。在 12 个月的随访期间，每 3 个月使用在线决策支持工具调整治疗。结果是增量成本每获得的质量调整生命年，哮喘控制（ACQ 评分），生活质量（哮喘生活质量问卷评分），哮喘药物使用和严重恶化率。
结果
611 名参与者被分配到 PCa（n=219），Ca（n=203）或 FCa（n=189）策略。FCa 策略与 PCa 策略相比改善了哮喘控制（P<0.02）。生活质量没有差异（P≥0.36）。与 Ca 策略相比，PCa 和 FCa 策略的哮喘药物使用明显较低（药物费用：PCa，$452；Ca，$551；和 FCa，$456；P≤0.04）。在愿意支付 50,000 美元/质量调整生命年的情况下，FCa 策略具有最高的成本效益概率（86%；PCa，2%；Ca，12%）。严重恶化率没有差异。
结论
症状加 Feno 驱动的策略可减少哮喘药物的使用，同时维持哮喘控制和生活质量，是初级保健中成年哮喘患者的首选策略。
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