社区医师对脑卒中二级预防可控危险因素的认知情况及培训效果研究
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摘要
背景脑卒中后二级预防对于患者预防血管并发症、再发脑卒中具有重要意义,社区医师是开展脑卒中防治工作的重要力量。目的了解社区医师对脑卒中二级预防可控危险因素的认知情况,评价对社区医师进行相关培训的效果。方法于2017年5月—2018年5月采用单纯随机抽样法在北京市门头沟区12家社区卫生服务中心中选取执业范围为内科或全科的社区医师50例,进行脑卒中二级预防可控危险因素相关知识培训。培训内容包括对脑卒中患者血压、血糖、血脂、心房颤动、抗血小板治疗的规范化二级预防治疗与管理。分别于培训前和培训后对纳入社区医师进行相关知识考核,比较培训前后的合格率,采用柏拉图分析法探讨培训未达标项(合格率<90.0%)的影响因素。结果培训前,社区医师血压相关知识的合格率达80.0%,其他因素相关知识的合格率均<80.0%。培训后,社区医师对血压、血糖、血脂、心房颤动、抗血小板治疗相关知识的合格率均高于培训前(P<0.05);对血压、血糖、血脂、抗血小板治疗相关知识的培训达标[合格率分别为100.0%(50/50)、92.0%(46/50)、90.0%(45/50)、96.0%(48/50)],对心房颤动相关知识的培训未达标[合格率为70.0%(35/50)]。柏拉图分析结果表明,导致社区医师对心房颤动相关知识培训未达标的主要影响因素为:对抗凝药物的了解(40.0%,20/50)、心房颤动抗凝适应证的掌握(28.0%,14/50)、心房颤动抗凝出血风险的评估(18.0%,9/50)。结论目前社区医师对脑卒中二级预防主要可控危险因素的认知不足,对血压相关知识的认知较好,对心房颤动相关知识的认知较差,规范性培训可以提高其认知水平。
Background For stroke patients,secondary prevention is of great significance in preventing the incidence of vascular complications and recurrence of stroke.Community physicians play a major role in the prevention and treatment of stroke.Objective To evaluate community physicians' pre-training and post-training awareness levels of the controllable risk factors in secondary prevention of stroke,and based on this,to assess the training effect.Methods By use of simple random sampling,we selected 50 community physicians whose scope of practice is internal medicine or general practice from 12 community health centers in Mentougou District of Beijing from May 2017 to May 2018.They received a training about controllable risk factors in secondary prevention of stroke,including standardized secondary prevention and management of abnormal blood pressure,blood glucose and blood lipids,and atrial fibrillation,and the management of antiplatelet aggregation therapy.Before and after the training,the participants received an assessment of the awareness level of the related data,respectively,and the pre-and post-training qualified rates in each aspect were compared to evaluate the training effect.In terms of the aspects of knowledge that the participants still mastered unsatisfactorily after training(qualified rate <90.0%),Pareto analysis was used to explore the associated factors. Results Before training,the percentage of participants with a qualified mastery of the knowledge about blood pressure management for stroke was 80.0%,but the percentages with a qualified mastery of the knowledge about blood glucose,blood lipids,atrial fibrillation,and antiplatelet aggregation therapy were all less than 80.0%.After training,the percentages of participants with a qualified mastery of the knowledge of the 5 aspects increased significantly compared with pre-training(P<0.05).Except for the aspect of management of atrial fibrillation [pass rate was 70.0%(35/50)],the percentages of participants who had a qualified mastery of the knowledge of other 4 aspects reached the desired requirements [pass rate were 100.0%(50/50),92.0%(46/50),90.0%(45/50),96.0%(48/50)].Pareto analysis found that,the awareness level of anticoagulant drugs(40.0%,20/50),mastery of the indications of anticoagulation in atrial fibrillation(28.0%,14/50) and bleeding risk assessment of anticoagulant treatment for atrial fibrillation(18.0%,9/50) were factors associated with the unsatisfactory training effect of atrial fibrillation management.Conclusion In general,the awareness level of controllable risk factors in secondary prevention of stroke is inadequate in community physicians.To be specific,they have a good mastery of the knowledge of blood pressure management,but have an unsatisfactory mastery of the knowledge of atrial fibrillation management.Corresponding standardized training can improve their awareness levels of such knowledge.
Background For stroke patients,secondary prevention is of great significance in preventing the incidence of vascular complications and recurrence of stroke.Community physicians play a major role in the prevention and treatment of stroke.Objective To evaluate community physicians' pre-training and post-training awareness levels of the controllable risk factors in secondary prevention of stroke,and based on this,to assess the training effect.Methods By use of simple random sampling,we selected 50 community physicians whose scope of practice is internal medicine or general practice from 12 community health centers in Mentougou District of Beijing from May 2017 to May 2018.They received a training about controllable risk factors in secondary prevention of stroke,including standardized secondary prevention and management of abnormal blood pressure,blood glucose and blood lipids,and atrial fibrillation,and the management of antiplatelet aggregation therapy.Before and after the training,the participants received an assessment of the awareness level of the related data,respectively,and the pre-and post-training qualified rates in each aspect were compared to evaluate the training effect.In terms of the aspects of knowledge that the participants still mastered unsatisfactorily after training(qualified rate <90.0%),Pareto analysis was used to explore the associated factors. Results Before training,the percentage of participants with a qualified mastery of the knowledge about blood pressure management for stroke was 80.0%,but the percentages with a qualified mastery of the knowledge about blood glucose,blood lipids,atrial fibrillation,and antiplatelet aggregation therapy were all less than 80.0%.After training,the percentages of participants with a qualified mastery of the knowledge of the 5 aspects increased significantly compared with pre-training(P<0.05).Except for the aspect of management of atrial fibrillation [pass rate was 70.0%(35/50)],the percentages of participants who had a qualified mastery of the knowledge of other 4 aspects reached the desired requirements [pass rate were 100.0%(50/50),92.0%(46/50),90.0%(45/50),96.0%(48/50)].Pareto analysis found that,the awareness level of anticoagulant drugs(40.0%,20/50),mastery of the indications of anticoagulation in atrial fibrillation(28.0%,14/50) and bleeding risk assessment of anticoagulant treatment for atrial fibrillation(18.0%,9/50) were factors associated with the unsatisfactory training effect of atrial fibrillation management.Conclusion In general,the awareness level of controllable risk factors in secondary prevention of stroke is inadequate in community physicians.To be specific,they have a good mastery of the knowledge of blood pressure management,but have an unsatisfactory mastery of the knowledge of atrial fibrillation management.Corresponding standardized training can improve their awareness levels of such knowledge.
引文
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[7]郭吉平,黄久仪.社区医师在脑卒中早期识别与转诊中的作用[J].中国全科医学,2013,16(15):1805-1807.DOI:10.3969/j.issn.1007-9572.2013.05.111.GUO J P,HUANG J Y.The role of community physicians in the early stroke identification and referral[J].Chinese General Practice,2013,16(15):1805-1807.DOI:10.3969/j.issn.1007-9572.2013.05.111.
[8]中华医学会神经病学分会.中国缺血性脑卒中和短暂性脑缺血发作二级预防指南2014[J].中华神经科杂志,2015,48(4):258-273.DOI:10.3760/cma.j.issn.1006-7876.2015.04.003.Chinese Society of Neurology.Secondary prevention guideline for ischemic stroke and transient ischemic attack in China 2014[J].Chinese Journal of Neurology,2015,48(4):258-273.DOI:10.3760/cma.j.issn.1006-7876.2015.04.003.
[9]范晨,胡成进.某军队医院门急诊检验服务患者不满意情形的柏拉图分析[J].实用医药杂志,2018,35(5):474-476.DOI:10.14172/j.issn1671-4008.2018.05.029.FAN C,HU C J.Plato analysis of dissatisfaction in outpatient and emergency department service in a military hospital[J].Practical Journal of Medicine&Pharmacy,2018,35(5):474-476.DOI:10.14172/j.issn1671-4008.2018.05.029.
[10]BRIDGWOOD B,LAGER K E,MISTRI A K,et al.Interventions for improving modifiable risk factor control in the secondary prevention of stroke[J].Cochrane Database Syst Rev,2014,2(5):CD009103.DOI:10.1002/14651858.CD009103.pub2.
[11]AMARENCO P,LAVALLéE P C,TAVARES L M,et al.Fiveyear risk of stroke after TIA or minor ischemic stroke[J].NEngl J Med,2018,378(23):2182-2190.DOI:10.1056/NEJMoa1802712.
[12]陈胜云,孙海欣,赵性泉,等.北京市社区卫生服务中心医务人员卒中相关知识调查及干预研究[J].中国卒中杂志,2010,5(9):716-722.DOI:10.3969/j.issn.1673-5765.2010.09.006.CHEN S Y,SUN H X,ZHAO X Q,et al.Survey and intervention study on the cognitive level of stroke-related knowledge among Beijing community medical staff[J].Chinese Journal of Stroke,2010,5(9):716-722.DOI:10.3969/j.issn.1673-5765.2010.09.006.
[13]张杰.重庆市主城区社区医护人员对脑卒中防治管理能力的调查研究[D].重庆:重庆医科大学,2013.
[14]GAYNOR E,ROHDE D,LARGE M,et al.Cognitive impairment,vulnerability,and mortality post ischemic stroke:a five-year follow-up of the action on secondary prevention interventions and rehabilitation in stroke(ASPIRE-S)cohort[J].J Stroke Cerebrovasc Dis,2018,27(9):2466-2473.DOI:10.1016/j.jstrokecerebrovasdis.2018.05.002.
[15]高素玲,刘国荣,陈瑞英,等.影响糖尿病并发急性脑梗死近期预后的相关因素分析[J].中华老年心脑血管病杂志,2015,17(11):1206-1207.GAO S L,LIU G R,CHEN R Y,et al.Analysis of related factors affecting the short-term prognosis of diabetes complicated with acute cerebral infarction[J].Chinese Journal of Geriatric Heart Brain and Vessel Diseases,2015,17(11):1206-1207.
[16]陈斌.基层医护人员对脑卒中二级预防的认知现状[J].内科,2015,10(3):380-382.DOI:10.16121/j.cnki.cn45-1347/r.2015.03.41.CHEN B.Cognition status of primary care workers on secondary prevention of stroke[J].Internal Medicine of China,2015,10(3):380-382.DOI:10.16121/j.cnki.cn45-1347/r.2015.03.41.
[17]高彩红,安强,宋珏娴.缺血性脑卒中患者心房颤动检出率及其影响因素的临床研究[J].中华老年心脑血管病杂志,2018,20(10):1027-1031.DOI:10.3969/j.issn.1009-0126.2018.10.006.GAO C H,AN Q,SONG J X.Detection rate of atrial fibrillation and its influencing factors in acute ischemic stroke patients[J].Chin J Geriatr Heart Brain Ves Dis,2018,20(10):1027-1031.DOI:10.3969/j.issn.1009-0126.2018.10.006.
[18]KIRCHHOF P,BENUSSI S,KOTECHA D,et al.2016 ESCguidelines for the management of atrial fibrillation developed in collaboration with EACTS[J].Europace,2016,18(11):1609-1678.DOI:10.1093/europace/euw295.
[2]CHIN Y Y,SAKINAH H,ARYATI A,et al.Prevalence,risk factors and secondary prevention of stroke recurrence in eight countries from south,east and southeast Asia:a scoping review[J].Med J Malaysia,2018,73(2):90-99.
[3]LINDSAY P,FURIE K L,DAVIS S M,et al.World Stroke Organization global stroke services guidelines and action plan[J].Int J Stroke,2014,9(suppl A100):4-13.DOI:10.1111/ijs.12371.
[4]AMJ D,HALPIN S,TWYMAN L,et al.Prevent 2nd,Stroke:a pilot study of an online secondary prevention program for stroke survivors[J].Aust N Z J Public Health,2018,42(5):484-490.DOI:10.1111/1753-6405.12794.
[5]HEUSCHMANN P U,KIRCHER J,NOWE T,et al.Control of main risk factors after ischaemic stroke across Europe:data from the stroke-specific module of the EUROASPIREⅢsurvey[J].European Journal of Preventive Cardiology,2015,22(10):1354-1362.DOI:10.1177/2047487314546825.
[6]HALL P,WILLIAMS D,HICKEY A,et al.Access to rehabilitation at six months post stroke:a profile from the action on secondary prevention interventions and rehabilitation in stroke(ASPIRE-S)study[J].Cerebrovascular Diseases,2016,42(3/4):247-254.DOI:10.1159/000446080.
[7]郭吉平,黄久仪.社区医师在脑卒中早期识别与转诊中的作用[J].中国全科医学,2013,16(15):1805-1807.DOI:10.3969/j.issn.1007-9572.2013.05.111.GUO J P,HUANG J Y.The role of community physicians in the early stroke identification and referral[J].Chinese General Practice,2013,16(15):1805-1807.DOI:10.3969/j.issn.1007-9572.2013.05.111.
[8]中华医学会神经病学分会.中国缺血性脑卒中和短暂性脑缺血发作二级预防指南2014[J].中华神经科杂志,2015,48(4):258-273.DOI:10.3760/cma.j.issn.1006-7876.2015.04.003.Chinese Society of Neurology.Secondary prevention guideline for ischemic stroke and transient ischemic attack in China 2014[J].Chinese Journal of Neurology,2015,48(4):258-273.DOI:10.3760/cma.j.issn.1006-7876.2015.04.003.
[9]范晨,胡成进.某军队医院门急诊检验服务患者不满意情形的柏拉图分析[J].实用医药杂志,2018,35(5):474-476.DOI:10.14172/j.issn1671-4008.2018.05.029.FAN C,HU C J.Plato analysis of dissatisfaction in outpatient and emergency department service in a military hospital[J].Practical Journal of Medicine&Pharmacy,2018,35(5):474-476.DOI:10.14172/j.issn1671-4008.2018.05.029.
[10]BRIDGWOOD B,LAGER K E,MISTRI A K,et al.Interventions for improving modifiable risk factor control in the secondary prevention of stroke[J].Cochrane Database Syst Rev,2014,2(5):CD009103.DOI:10.1002/14651858.CD009103.pub2.
[11]AMARENCO P,LAVALLéE P C,TAVARES L M,et al.Fiveyear risk of stroke after TIA or minor ischemic stroke[J].NEngl J Med,2018,378(23):2182-2190.DOI:10.1056/NEJMoa1802712.
[12]陈胜云,孙海欣,赵性泉,等.北京市社区卫生服务中心医务人员卒中相关知识调查及干预研究[J].中国卒中杂志,2010,5(9):716-722.DOI:10.3969/j.issn.1673-5765.2010.09.006.CHEN S Y,SUN H X,ZHAO X Q,et al.Survey and intervention study on the cognitive level of stroke-related knowledge among Beijing community medical staff[J].Chinese Journal of Stroke,2010,5(9):716-722.DOI:10.3969/j.issn.1673-5765.2010.09.006.
[13]张杰.重庆市主城区社区医护人员对脑卒中防治管理能力的调查研究[D].重庆:重庆医科大学,2013.
[14]GAYNOR E,ROHDE D,LARGE M,et al.Cognitive impairment,vulnerability,and mortality post ischemic stroke:a five-year follow-up of the action on secondary prevention interventions and rehabilitation in stroke(ASPIRE-S)cohort[J].J Stroke Cerebrovasc Dis,2018,27(9):2466-2473.DOI:10.1016/j.jstrokecerebrovasdis.2018.05.002.
[15]高素玲,刘国荣,陈瑞英,等.影响糖尿病并发急性脑梗死近期预后的相关因素分析[J].中华老年心脑血管病杂志,2015,17(11):1206-1207.GAO S L,LIU G R,CHEN R Y,et al.Analysis of related factors affecting the short-term prognosis of diabetes complicated with acute cerebral infarction[J].Chinese Journal of Geriatric Heart Brain and Vessel Diseases,2015,17(11):1206-1207.
[16]陈斌.基层医护人员对脑卒中二级预防的认知现状[J].内科,2015,10(3):380-382.DOI:10.16121/j.cnki.cn45-1347/r.2015.03.41.CHEN B.Cognition status of primary care workers on secondary prevention of stroke[J].Internal Medicine of China,2015,10(3):380-382.DOI:10.16121/j.cnki.cn45-1347/r.2015.03.41.
[17]高彩红,安强,宋珏娴.缺血性脑卒中患者心房颤动检出率及其影响因素的临床研究[J].中华老年心脑血管病杂志,2018,20(10):1027-1031.DOI:10.3969/j.issn.1009-0126.2018.10.006.GAO C H,AN Q,SONG J X.Detection rate of atrial fibrillation and its influencing factors in acute ischemic stroke patients[J].Chin J Geriatr Heart Brain Ves Dis,2018,20(10):1027-1031.DOI:10.3969/j.issn.1009-0126.2018.10.006.
[18]KIRCHHOF P,BENUSSI S,KOTECHA D,et al.2016 ESCguidelines for the management of atrial fibrillation developed in collaboration with EACTS[J].Europace,2016,18(11):1609-1678.DOI:10.1093/europace/euw295.