作者：Laurie Barclay, MD 齣處：WebMD醫學新聞 　　September 8, 2009 — 根據一項在8月29日發錶於Lancet的研究結果 ADO指標 ADO指標可能協助預測COPD患者死亡風險 - 趣味新聞網

發表日期 2009-09-24T05:25:34+08:00

     本帖最後由 lsc0019 於 2009-9-24 21:44 編輯

作者：Laurie Barclay, MD
齣處：WebMD醫學新聞

September 8, 2009 — 根據一項在8月29日發錶於Lancet的研究結果，ADO指標，一個預測病患死於慢性阻塞性肺病（COPD）的新指標，顯然比目前使用的BODE指標好。

來自馬裏蘭巴爾的摩彭博約翰霍普金斯公共衛生學院的Milo A. Puhan博士與其同事們錶示，BODE指標（包括身體質量指數[BMI]、氣流阻塞、呼吸睏難與運動功能）對罹患COPD病患預後評估有重要的貢獻。

然而，目前沒有研究評估BODE指標預測的死亡風險，是否與不同族群間觀察到的死亡率相符。我們評估校正BODE指標，更新以改善校正結果，並發展及確效一個簡化的指標，用於初級照護。

這項研究樣本包括232位來自瑞典Barmelweid族群的病患，這些病患都罹患長期、嚴重的COPD，以及342位來自西班牙錶現型與COPD病程族群，這些病患都曾因為中重度COPD而首次住院。研究將比較這兩個族群3年所有原因死亡率，以及BODE指標所預測的風險。研究者接著根據瑞士族群，改寫BODE指標，並發展簡化的ADO指標（包括年齡、呼吸睏難與氣流阻塞）。

BODE指標的校正不佳。在瑞士族群中，3年死亡風險相對低估瞭36%（預測風險中位數為21.7%；四分位數範圍[IQR]為12.7%-31.7%，相較於觀察到的風險34.1%；P= 0.013）。相對的，西班牙族群風險高估瞭39%（16.7%；IQR為12.7%-31.7%相較於12.0%；P= 0.035）。

以更新的BODE指標在西班牙族群觀察到的死亡率與預測的3年死亡風險比較相符（中位數10.7%；IQR為8.1%-13.8%；P=0.99），新的ADO指標也是如此（中位數11.8%；IQR為9.1%-14.3%；P=0.98）。

更新的BODE與ADO指標可以引領COPD病患在專科或初級照護情況下，支持預後評估。這樣的評估增加瞭對個彆病患的標的治療。

這項研究的限製包括瑞典與西班牙族群研究計劃不同、且相對樣本數目較小。

在隨後的主編評論中，來自加拿大安大略漢米爾敦曼徹斯特大學健康科學中心的Holger Schunemann醫師，討論預後資訊的適當使用。

Schunemann醫師指齣，透過預後研究確認基礎風險可能協助標的治療，對於發展治療指引也會有重要且長期需求的貢獻。然而，每個決定都有優缺點，且如果這不會改變病患處理與整體利益的話，也是徒勞無功的。

這項研究由瑞士國傢科學基金會；Klinik Barmelweid；西班牙衛生機關Fondo de Investigacion Sanitaria；加泰隆尼亞政府Agencia d'Avaluacio de Tecnologia i Recerca Mediques；西班牙肺髒與胸腔外科學會；Catalan Foundation of Pneumology；Red RESPIRA；Red RCESP；Fondo de Investigacion Sanitaria；Fondo de Investigacion Sanitaria；Fundacio La Marato de TV3與諾華藥廠西班牙分公司贊助。

研究作者們錶示，雖然過去與藥廠有資金上的關係，但已沒有相關資金上的往來。完整的描述在原始文章中。Schunemann醫師與Puhan共事多年，指導他的博士論文，目前仍然閤作中。

ADO Index May Help Predict Risk for Mortality From COPD

By Laurie Barclay, MD
Medscape Medical News

September 8, 2009 — The ADO index, a new score for predicting a patient's risk of dying of chronic obstructive pulmonary disease (COPD), appears to perform better than the currently used BODE index, according to the results of a study reported in the August 29 issue of The Lancet.

"The BODE index (including body-mass index [BMI], airflow obstruction, dyspnoea, and exercise capacity) was an important contribution to the prognostic assessment of patients with...COPD," write Milo A. Puhan, PhD, from the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, and colleagues.

"However, no study has assessed whether the risk of mortality predicted by the BODE index matches the observed mortality in different populations. We assessed the calibration of the BODE index, updated it to improve its calibration, and developed and validated a simplified index for use in primary-care settings."

The study sample consisted of 232 patients from the Swiss Barmelweid cohort with longstanding and severe COPD and 342 patients from the Spanish Phenotype and Course of COPD cohort study who had had their first hospitalization for moderate to severe COPD. The observed 3-year risk for all-cause mortality was compared vs the risk predicted by the BODE index in both cohorts. The investigators then revised the BODE index and developed a simplified ADO index (including age, dyspnea, and airflow obstruction) from the Swiss cohort. Both measures were validated in the Spanish cohort.

There was poor calibration of the BODE index. In the Swiss cohort, there was a 36% relative underprediction of 3-year mortality risk (median predicted risk, 21.7%; interquartile range [IQR], 12.7% - 31.7% vs 34.1% observed risk; P = .013). In contrast, there was 39% relative overprediction in the Spanish cohort (16·7%; IQR, 12.7% - 31.7% vs 12.0%; P = .035).

Prediction of 3-year mortality risk was a good match to the mortality rate observed in the Spanish cohort with use of either the updated BODE (median, 10.7%; IQR, 8.1% - 13.8%; P = .99) or the new ADO index (median, 11.8%; IQR, 9.1% - 14.3%; P = .98).

"Both the updated BODE and ADO indices could lend support to the prognostic assessment of patients with COPD in specialised and primary-care settings," the study authors write. "Such assessment enhances the targeting of treatments to individual patients."

Limitations of the study include different protocols for the Swiss and the Spanish cohorts and relatively small sample size.

In an accompanying comment, Holger Schunemann, MD, PhD, from McMaster University Health Sciences Centre in Hamilton, Ontario, Canada, discusses appropriate use of prognostic information.

"Identification of baseline risks through prognostic studies might help to target therapy and can make important and long-needed contributions to, for instance, guideline development," Dr. Schunemann writes. "However, every decision has benefits and downsides, and it is futile to provide prognostic data if it does not lead to altered management and net benefit for the patient."

Funding for this study was provided by Swiss National Science Foundation; Klinik Barmelweid; Fondo de Investigacion Sanitaria Ministry of Health, Spain; Agencia d'Avaluacio de Tecnologia i Recerca Mediques, Catalonia Government; Spanish Society of Pneumology and Thoracic Surgery; Catalan Foundation of Pneumology; Red RESPIRA; Red RCESP; Fondo de Investigacion Sanitaria; Fondo de Investigacion Sanitaria; Fundacio La Marato de TV3; and Novartis Farmaceutica, Spain.

The study authors have disclosed no relevant financial relationships, despite previous financial relationships with pharmaceutical companies. A complete description is available in the original article. Dr. Schunemann worked closely for several years with Dr. Puhan, supervised his PhD thesis, and still collaborates with him.

Lancet. 2009;374:667-668, 704-711.

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