家庭医生在多重慢病患者诊疗中潜在不合理用药情况及培训需求分析

黄倩; 徐昕; 邵洁; 张芳; 朱敏; 周路路; 张胜冰; 黄蛟灵; 刘葳

doi:10.16766/j.cnki.issn.1674-4152.003339

家庭医生在多重慢病患者诊疗中潜在不合理用药情况及培训需求分析

doi: 10.16766/j.cnki.issn.1674-4152.003339

黄倩¹,
徐昕^1, ,,
邵洁¹,
张芳¹,
朱敏¹,
周路路¹,
张胜冰¹,
黄蛟灵²,
刘葳³

1.
上海市浦东新区潍坊社区卫生服务中心，上海 200122
2.
上海交通大学医学院公共卫生学院，上海 200125
3.
上海市黄浦区打浦桥社区卫生服务中心，上海 200125

基金项目:

上海市浦东新区卫健委学科带头人培养计划项目 PWRd2021-08

上海市浦东新区科技发展基金民生科研专项资金项目 PKJ2019-Y48

上海市“医苑新星”青年医学人才培养资助计划项目沪卫人事[2022]65号

详细信息

通讯作者:
徐昕，E-mail: xuxin211@126.com

中图分类号: R969.3 R192.3
计量
- 文章访问数: 158
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- PDF下载量: 9
- 被引次数: 0
出版历程
- 收稿日期: 2023-01-09
- 网络出版日期: 2024-03-09

Analysis of potential irrational drug use and training needs of family doctors in the diagnosis and treatment of patients with multiple chronic diseases

1.
Weifang Community Health Service Center, Pudong New Area, Shanghai 200122, China

摘要

摘要: 目的对社区全科医生在多病共存患者潜在不合理用药情况进行调研，探讨提升策略。方法对本项目组前期研究检验出社区潜在不合理用药(PIM)项目21项设计田野调查问卷。于2021年12月—2022年1月使用机械式抽样方法对上海市浦东新区47家社区卫生服务中心在岗的236名全科医生抽取共计1 500张处方，并进行在线问卷调研。结果 21项PIM出现频率最高的项目为“地高辛用于心室收缩功能正常的心力衰竭患者”“使用袢利尿剂治疗无心力衰竭临床表现的依赖性踝部水肿”等，对PIM条目的主观出现频率判断、全科医生的主观合理性判断、处方中实际出现客观频率进行两两差异性分析，秩和检验提示：21项潜在不合理用药条目主观合理性判断和客观出现频率相比，差异均有统计学意义(P＜0.05)；21项潜在不合理用药条目主观出现频率判断和主观合理性判断相比，除“硝苯地平常释剂型作为降压药物”条目二者差异无统计学意义(P＞0.05)，其余条目差异均有统计学意义(P＜0.01)；以21个PIM的日常出现频率评估为因变量，以职称、学历等5个因素作为自变量进行线性回归分析，结果显示各因素均非PIM日常出现频率的影响因素(P＞0.05)。结论目前家庭医生对多重慢病患者的潜在不合理用药尚缺乏主观认知，且较为普遍，应开展统一培训指导。
- 共存病 /
- 不合理用药 /
- 培训 /
- 需求 /
- 家庭医生
Abstract: Objective To investigate the potential irrational drug use among community general practitioners in patients with multimorbidity diseases, and explore improvement strategies. Methods Twenty-one field research questionnaires of community potentially inappropriate medications (PIM) project were tested in the previous study of this project group. A total of 1 500 prescriptions were collected from 236 general practitioners on duty at 47 community health service centers from December 2021 to January 2022 in Pudong New Area, Shanghai using mechanical sampling method, and an online questionnaire survey was conducted. Results The 21 items with the highest frequency of PIM were "Digoxin for heart failure patients with normal ventricular systolic function", "ankle edema dependent on clinical manifestations of non-heart failure treated with loop Diuretic", etc. The difference analysis was made on the subjective frequency of PIM items, the subjective rationality judgment of general practitioners, and the actual objective frequency in prescriptions. The rank sum test suggested that there was a statistically significant difference between the subjective rationality judgment and objective occurrence frequency of 21 potentially irrational drug use items (P < 0.05); Compared with the subjective frequency judgment and subjective rationality judgment of 21 potential irrational drug use items, there was no significant difference between the two items except for the item "Nifedipine regular release dosage form as antihypertensive drug" (P > 0.05), and the other items had significant differences (P < 0.01); Linear regression analysis was conducted using the daily occurrence frequency of 21 PIMs as the dependent variable and 5 factors such as professional title and education as independent variables. The results showed that each factor had no significant impact on the daily occurrence frequency of PIMs (P > 0.05). Conclusion Currently, family doctors lack subjective understanding of the potential irrational use of medication in patients with multiple chronic diseases, and it is relatively common. Therefore, unified training and guidance should be carried out.
- Multimorbidity /
- Irrational drug use /
- Training /
- Needs /
- Family doctor

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表 1 236名全科医生的基本情况

Table 1. Basic information of 236 general practitioners

项目	类别	人数	百分比(%)
性别	男性	70	29.7
	女性	166	70.3
年龄(岁)	≤30	26	11.0
	>30~40	117	49.6
	>40~50	85	36.0
	＞50	8	3.4
职称	初级	28	11.9
	中级	183	77.5
	副高级	25	10.6
学历	大专及以下	10	4.2
	本科	191	80.9
	研究生及以上	35	14.8
是否经过规培	是	104	44.1
	否	132	55.9
社区工作时长(年)	≤10	169	71.6
	>10~20	57	24.2
	＞20~30	10	4.2
签约服务人数(人)	≤1 000	65	27.5
	＞1 000~2 000	159	67.4
	＞2 000~3 000	12	5.1
平台评级	A级	108	45.8
	B级	78	33.1
	C级	42	17.8
	D级	8	3.4

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表 2 社区常见潜在不合理用药情况

Table 2. Common potential irrational drug use in the community

编号	PIM条目名称	处方中出现的数目	占所有抽样处方的百分比(%)
T1	地高辛用于心室收缩功能正常的心力衰竭患者	7	0.47
T2	使用袢利尿剂治疗无心力衰竭临床表现的依赖性踝部水肿(无有效性证据，使用弹力袜通常更有效)	5	0.33
T3	单一使用袢利尿剂作为高血压的一线治疗方案(有更加安全有效的备选方案)	4	0.27
T4	有痛风史的患者使用嗪类利尿剂(可能加重痛风)	4	0.27
T5	β-受体阻滞剂用于无心动过缓(心率＜50次/min)Ⅱ型房室传导阻滞或者完全性房室传导阻滞，存在完全性房室传导阻滞和心搏停止风险	1	0.07
T6	没有冠状动脉、脑血管、周围血管病或动脉闭塞事件者使用阿司匹林(没有指征)	5	0.33
T7	苯二氮类药物应用时间超过28 d(更长疗程用药无指征)有造成长时间镇静意识障碍、损害平衡能力、跌倒、发生交通事故的风险; 所有苯二氮类药物应用时间超过4周时应逐渐减量, 若突然停药可能出现戒断综合征	53	3.53
T8	无并发症的消化性溃疡或糜烂性食管炎患者使用全剂量质子泵抑制剂时间超过8周(应减低剂量或及早停药)	36	2.40
T9	含铝抗酸剂用于慢性便秘患者	5	0.33
T10	慢性阻塞性肺疾病应用茶碱作为单药治疗药物(有安全、有效的可选药物: 治疗窗, 易导致不良反应)	4	0.27
T11	选用NSAIDs而非COX-2抑制剂用于有消化性溃疡史或消化道出血患者，除非联用PPI或H₂受体阻滞剂(可致消化性溃疡复发)	16	1.07
T12	频繁(≥1次/月)发生低血糖的糖尿病患者使用β-受体阻滞剂(有掩盖低血糖症状的风险)	1	0.07
T13	慢性心房颤动患者应接受华法林抗凝治疗	4	0.27
T14	稳定性心绞痛应接受β-受体阻滞剂治疗	3	0.20
T15	使用口服糖皮质激素维持治疗的患者同时给予双膦酸盐	1	0.07
T16	2型糖尿病无论有无代谢综合征均应接受二甲双胍治疗(无肾功能损伤)	3	0.20
T17	糖尿病患者如果同时存在一个或多个主要心血管风险因素应该接受他汀类药物治疗	4	0.27
T18	胺碘酮用作心房颤动一线药物	1	0.07
T19	硝苯地平常释剂型作为降压药物	2	0.13
T20	苯二氮类(镇静作用，引起感觉系统功能降低。损伤平衡力)	13	0.87
T21	ACEI与阿米洛利或氨苯蝶啶联用	2	0.13

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表 3 PIM客观出现频率和全科医生对PIM的主观评价比较

Table 3. Comparison of objective frequency of PIM and subjective evaluation of PIM by general practitioners

条目	PIM客观出现频率(次)		PIM主观评价(人次)		Z值	P值
条目	存在不合理用药	不存在不合理用药	认为存在PIM	不认为存在PIM	Z值	P值
T1	7	353	48	140	-8.716	＜0.001
T2	5	355	47	144	-8.864	＜0.001
T3	4	356	42	154	-8.301	＜0.001
T4	4	356	46	152	-8.746	＜0.001
T5	1	359	40	169	-8.380	＜0.001
T6	5	355	57	143	-9.788	＜0.001
T7	53	307	84	108	-7.513	＜0.001
T8	36	324	63	123	-6.855	＜0.001
T9	36	324	63	123	-8.751	＜0.001
T10	5	355	48	152	-8.378	＜0.001
T11	4	356	43	155	-6.152	＜0.001
T12	16	344	39	144	-8.219	＜0.001
T13	4	356	77	112	-12.429	＜0.001
T14	3	357	50	128	-9.973	＜0.001
T15	1	359	60	116	-11.565	＜0.001
T16	3	357	54	127	-10.357	＜0.001
T17	4	356	50	131	-9.698	＜0.001
T18	1	359	47	140	-9.737	＜0.001
T19	2	358	75	111	-12.641	＜0.001
T20	13	347	54	125	-8.793	＜0.001
T21	2	358	44	140	-9.255	＜0.001

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表 4 PIM日常出现频率估计和全科医生对PIM的主观评价比较

Table 4. Comparison of estimation of daily occurrence frequency of PIM and subjective evaluation of PIM by general practitioners

条目	日常出现频率估计(人次)		主观评价(人次)		Z值	P值
条目	日常频率低	日常频率高	认为存在PIM	不认为存在PIM	Z值	P值
T1	98	92	48	140	-5.194	＜0.001
T2	102	86	47	144	-5.900	＜0.001
T3	143	44	42	154	-10.761	＜0.001
T4	195	20	46	152	-13.877	＜0.001
T5	191	23	40	169	-14.464	＜0.001
T6	101	74	57	143	-5.708	＜0.001
T7	127	48	84	108	-5.571	＜0.001
T8	147	35	63	123	-9.075	＜0.001
T9	155	29	63	123	-11.798	＜0.001
T10	148	38	48	152	-11.317	＜0.001
T11	175	24	43	155	-13.089	＜0.001
T12	154	36	39	144	-12.123	＜0.001
T13	160	30	77	112	-8.730	＜0.001
T14	143	39	50	128	-9.589	＜0.001
T15	149	28	60	116	-9.561	＜0.001
T16	125	45	54	127	-8.172	＜0.001
T17	172	21	50	131	-12.084	＜0.001
T18	109	62	47	140	-7.349	＜0.001
T19	77	113	75	111	-0.040	0.968
T20	100	65	54	125	-5.664	＜0.001
T21	110	55	44	140	-8.019	＜0.001

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表 5 PIM日常出现频率评估的影响因素回归分析

Table 5. Linear regression analysis of influencing factors of PIM daily frequency

变量	B	SE	β	t值	P值	容差	VIF
职称	-0.112	0.098	-0.084	-1.148	0.252	0.796	1.257
学历	-0.041	0.114	-0.027	-0.356	0.722	0.732	1.367
是否经历过住院医师规范化培训	-0.119	0.099	-0.094	-1.203	0.230	0.704	1.420
担任社区卫生服务中心全科医师的时长	0.060	0.083	0.052	0.725	0.469	0.815	1.227
家庭医生服务的综合评价平台的分级	0.019	0.049	0.025	0.381	0.703	0.976	1.025

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