一种rguably the greatest therapeutic breakthroughs have resulted from increased medical specialisation, particularly in major disciplines, such as cardiology and respiratory medicine. Generalism now remains the province of primary and community care, and of elderly care teams. However, what works well for research may work against the delivery of these medical advances to the patients most in need. A movement away from the established reductionist approach in medicine may facilitate the delivery of best care for a number of reasons in both cardiology and respiratory medicine, as follows.
1) Huge efforts are currently directed at preventing repeat admissions from exacerbations of heart failure and chronic obstructive pulmonary disease (COPD), facilitating early discharge and managing patients in the community1–4。家support, including telecare, may help both groups. Moreover, a number of telecare schemes now have joint networks serving COPD and heart failure patients5。
2)肺和心脏康复计划是慢性心脏和呼吸患者的长期护理计划的关键和有效组分,但在许多中心康复计划中已经发展,并分别工作人员。虽然需要定制疾病的性质的程序及其严重程度,但课程可以轻松地互相协调,并分享设施和专业知识。此外,联合运动课程的作用应在心肺疾病的自然历史上提前审查。
3)睡眠无序的呼吸(SDB)在缺血性心脏病患者中越来越识别,其中阻塞性睡眠呼吸暂停(OSA)可以复合心脏风险。慢性心力衰竭患者也经历了SDB。然而,这前是被认为是一个终级现象,但最近的工作显示SDB在多达50%的患者中发生轻度至中度心力衰竭6,这些patients predominantly have central sleep apnoea (CSA)/Cheyne–Stokes respiration. While the evidence to support continuous positive airway pressure (CPAP) therapy in sleepy heart disease patents with OSA is secure7,8,争议在治疗CSA的价值上统治9,10。The identification of heart failure patients with SDB is problematic, as while OSA patients are sleepy, heart failure patients with CSA are not11。In many European centres, sleep services fall within the compass of respiratory medicine, so cardiology and respiratory medicine teams must work together to develop sensible, practical strategies for screening sleep studies and applying effective therapy. As a by-product, this cooperative approach will facilitate research trials determining, for example, whether CPAP reduces cardiovascular risk and symptoms in patients with mild to moderate OSA (MOSIAC trial, Oxford Sleep Unit/MRC Clinical Trials Unit, UK; in progress) or whether innovative approaches, such as adaptive servo-ventilation, improve cardiac outcomes in heart failure patients with central SDB12,13。由欧洲心脏和呼吸调查人员共同领导的服务HF试验刺激的合作方式,可作为一个有用的例子。
4) End-of-life care issues in heart failure and respiratory failure contain many similar elements14。虽然疗法可能不同,但关键的重点是支持支持性的护理,共享决策,症状控制和家庭支持。姑息治疗专家不能单独地合理地处理这种大量患者的载荷,因为来自癌症的心脏和呼吸道疾病的死亡。唯一的前进方向是为了传播患者护理的人的姑息和支持性护理专业知识。心脏病学和呼吸团队之间的人造障碍不会很好地为这些患者提供服务。
5)呼吸困难评估:随着普遍从业者和医院实践发生的越来越多的专业,往往依赖于患者看到谁,而不是最可能的诊断,指出需要更广泛的一站式/快速访问诊所。
6)最后,最明显的是,我们的许多患者都有共存心脏和呼吸系统疾病。虽然这方面可能被临床试验低估,但倾向于排除共同病理学,在老化患者的现实世界中,敏感的管理将始终拥抱所有条件,这些条件之间的相互作用15以及多酚疾病的影响16。读者无疑将指向呼吸医学和心脏病学团队之间共同合作的繁荣例子,但在欧洲之间这些是拼凑而成的,而不是系统组织或计划。
What is the greatest barrier to a cross-specialty approach? Probably doctors themselves. Other healthcare professionals often have a more flexible attitude and greater experience with multi-professional and multi-agency teamworking. Resistance to such an approach may be encouraged by the need to choose a specialty early in medical training, and diverging tracks and knowledge base as careers progress. Essentially though, there is no reason why we cannot fuse the advantages of specialism in research, where applicable, and the advantages of integration for the delivery of care. This approach does not deny that excellent, innovative academic research can be generated by the cross pollination of ideas, or that research into the processes and delivery of care is important. Indeed the latter is crying out for a robust evidence base17,18,而不是一个人为新的倡议19,20。例如,如果急性护理成本相对较高,则为医院 - at-Home计划的成本仅累积,并且可能不会在医疗保健系统或地理上轻松翻译19。
在大多数欧洲国家,有一个必须减少医院招生并使社区关注的必要条件。众多因素驱动此目的,包括成本和患者偏好。一些医疗保健团队成员认为这一威胁到目前的专业实践,以及政府对碎片护理的机会。在经济上,毫无疑问,需要进行护理的交付变化,从我们的患者的角度来看,这些举措是结合最佳的心脏病和呼吸实践,而不是均质,最低的普通分母方法。为此,次要和初级保健之间的综合方法可能产生最佳结果。我们的论文是,从医院到社区护理的这种垂直整合应该伴随着专业之间的横向整合。
所以,让我们打破障碍。有很多才能获得,并且很少才能丢失。
Statement of interest
一种statement of interest for A.K. Simonds and M.R. Cowie can be found atwww.www.qdcxjkg.com/misc/statements.shtml
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