背景:指南建议对新出现的呼吸困难或咯血进行紧急胸部X线检查,但很少有关于其实施的证据。
方法:我们分析了2012年4月至2017年3月期间30岁以上新出现呼吸困难或咯血的初级保健患者的相关初级保健和医院影像学数据。我们检查了指南一致性管理,定义为在症状表现后2周内进行全科医师的胸部X线/CT检查,以及使用逻辑回归的社会人口统计学特征和相关病史的差异。此外,在被诊断为癌症的患者中,我们描述了诊断时间,诊断路线和诊断阶段按指南一致状态进行。
结果:总计,22560/162161(13.9%)呼吸困难患者和4022/8120(49.5%)咯血患者在推荐的2周内接受了指南一致的影像学检查。近期胸部影像学显示的患者接受影像学检查的可能性要小得多(呼吸困难的校正OR0.16,95%CI0.14-0.18,并校正咯血的OR0.09,95%CI0.06-0.11)。慢性阻塞性肺疾病/哮喘的病史也与较低的指南一致性(呼吸困难:OR0.234,95%CI0.225-0.242和咯血:0.88,0.79-0.97)相关。在患有心力衰竭的呼吸困难患者中,指南一致性成像较低;当前或戒烟者;以及在社会经济上处于不利地位的人群中。在指南一致的影像学检查组中,12个月内肺癌诊断的可能性更大(呼吸困难:1.1%vs0.6%;咯血:3.5%vs2.7%)。
结论:接受紧急成像的可能性与随后癌症诊断的风险一致。然而,尽管符合资格,但大部分呼吸困难和咯血患者未接受及时的胸部成像,提示早期肺癌诊断的机会。
BACKGROUND: Guidelines recommend urgent chest X-ray for newly presenting dyspnoea or haemoptysis but there is little evidence about their implementation.
METHODS: We analysed linked primary care and hospital imaging data for patients aged 30+ years newly presenting with dyspnoea or haemoptysis in primary care during April 2012 to March 2017. We examined
guideline-concordant management, defined as General Practitioner-ordered chest X-ray/CT carried out within 2 weeks of symptomatic presentation, and variation by sociodemographic characteristic and relevant medical history using logistic regression. Additionally, among patients diagnosed with cancer we described time to diagnosis, diagnostic route and stage at diagnosis by guideline-concordant status.
RESULTS: In total, 22 560/162 161 (13.9%) patients with dyspnoea and 4022/8120 (49.5%) patients with haemoptysis received
guideline-concordant imaging within the recommended 2-week period. Patients with recent chest imaging pre-presentation were much less likely to receive imaging (adjusted OR 0.16, 95% CI 0.14-0.18 for dyspnoea, and adjusted OR 0.09, 95% CI 0.06-0.11 for haemoptysis). History of chronic obstructive pulmonary disease/asthma was also associated with lower odds of
guideline concordance (dyspnoea: OR 0.234, 95% CI 0.225-0.242 and haemoptysis: 0.88, 0.79-0.97).
Guideline-concordant imaging was lower among dyspnoea presenters with prior heart failure; current or ex-smokers; and those in more socioeconomically disadvantaged groups.The likelihood of lung cancer diagnosis within 12 months was greater among the guideline-concordant imaging group (dyspnoea: 1.1% vs 0.6%; haemoptysis: 3.5% vs 2.7%).
CONCLUSIONS: The likelihood of receiving urgent imaging concords with the risk of subsequent cancer diagnosis. Nevertheless, large proportions of dyspnoea and haemoptysis presenters do not receive prompt chest imaging despite being eligible, indicating opportunities for earlier lung cancer diagnosis.