Conocer y analizar el grado de acuerdo y desacuerdo en diagnosticar asma bronquial (AB) entre neumólogos y no neumólogos en el ámbito de atención primaria y especializada en un hospital comarcal.

Se estudian 96 pacientes (≥ 16 y ≤ 70 anos) de consulta externa en los que se diagnostica AB por parte del medico que remite al paciente o del neumologo. Se recogen: a) datos clinicos, determinando la probabilidad diagnostica inicial (PDI) de asma en alta, media o baja; b) espirometria, test broncodilatador (TBD), variabilidad de flujo espiratorio maximo y prueba de provocacion bronquial con metacolina, y c) prick test y determinacion de eosinofilos e IgE total en suero. Se registraron tres diagnosticos: el inicial (DI), del medico que remitia al paciente, quien desconocia el desarrollo del estudio; el del neumologo, obtenido solo con los datos clinicos (DCN), y el final (DF). En este ultimo caso, para diagnosticar AB se exigio una PDI alta o media y un test broncomotor positivo. Se estudia el grado de concordancia entre los tres diagnosticos mediante el test de Kappa (K), y mediante la prueba de la χ2 y analisis de la variancia se analizan las caracteristicas de los grupos con mayor o menor concordancia.

Se observó concordancia aceptable entre DCN y DF (K = 0,63) y muy baja entre DI-DCN y DI-DF. En estos dos casos, el grupo de pacientes con concordancia diagnóstica en AB presentaba mayor procedencia hospitalaria e IgE (p ≤0,05), así como PDI alta, tiempo de evolución y antecedentes de asma (p ≤0,01) (odds ratio: 59,8). Los pacientes discordantes lo eran fundamentalmente por ganancia en AB, con un infradiagnóstico del 39%. Éstos consultan sólo por algún síntoma relacionado con el asma (odds ratio: 119) y para su diagnóstico se requirió de pruebas broncomotoras distintas del TBD (p ≤0,01).

a) El grado de acuerdo a la hora de diagnosticar AB es bajo; b) el perfil clínico funcional de los pacientes en los que hay concordancia en AB difiere de aquellos en los que existe ganancia diagnóstica, y c) en las condiciones de nuestro estudio, se constata una amplia proporción de infradiagnóstico.

To determine and analyze the degree of agreement and disagreement in the diagnosis of bronchial asthma (BA) by respiratory disease specialists and generalists in regional hospital and primary care settings.

Ninety-six outpatients (16 to 70 years of age) were studied; all had been assigned a diagnosis of BA by the referring physician or by the respiratory disease specialist. We recorded 1) clinical symptoms, determining the initial probability of a diagnosis (IPD) of BA to be high, medium or low; 2) results of spirometry and bronchodilator testing (BDT), peak flow variability and methacholine challenge testing; 3) prick test results, eosinophil levels and total serum IgE levels. Three diagnoses were recorded: the initial diagnosis (ID) by the referring physician to whom follow-up data were unavailable; diagnosis by the respiratory disease specialist based only on clinical symptoms (RSS); and the final diagnosis (FD). To arrive at a FD of BA, it was necessary to have a high or medium IPD and a positive BDT. A Kappa test was used to analyze the degree of agreement among the three diagnoses. Group features associated with greater or lesser agreement were analyzed by chi-square tests and analysis of variance.

Agreement was acceptable between RSS and FD (K = 0.63) but very low between ID and RSS and between ID and FD. In the latter two cases, agreement was greatest for patients diagnosed in hospital and for those with high IgE levels (p < 0.05), with high IPD, longer course of disease and a history of asthma (p < 0.01) (odds ratio = 59.8). Diagnostic disagreement occurred mainly for patients for whom a BA diagnosis was gained later, the of under-diagnosis being 39%. The patients involved visited the physician only because they had observed an isolated symptom related to asthma (odds ratio = 119) and to arrive at a diagnosis bronchomotor tests other than BDT were required (p < 0.01).

a) The degree of agreement for a diagnosis of BA is low. b) The functional profile of patients for whom diagnostic agreement exists differs from that of patients for whom diagnosis is gained through testing. c) In the context of this study, a high rate of under-diagnosis is evident.