卒中专病门诊贯彻卒中二级预防指南的研究

The impact of stroke clinic on improving the compliance with the guidelines for secondary prevention of ischemic stroke

目的观察医师培训和专病门诊对缩小临床实践与缺血性卒中二级预防指南差距的影响。方法选择在卒中专病门诊就诊的305例缺血性卒中患者,比较其在医师规范培训前后及出院与在专病门诊随访期间抗栓药、他汀类药物、不规范用药和降压药的使用情况。结果医师经培训后提高了二级预防用药的规范性,患者出院的抗栓药(79.3%比93.1%,P<0.01)和他汀类药(19.5%对59.2%,P<0.01)使用率显著提高,不规范用药(47.1%比27.5%,P=0.001)显著降低。高血压的治疗率(88.4%比94.0%)差异无统计学意义。与出院时相比,专病门诊随访患者的抗栓药和他汀类药使用率进一步提高,不规范用药进一步降低。出院带药规范者随访期的用药依从性高。结论医师培训能提高缺血性卒中二级预防处方的规范性,专病门诊能进一步提高患者出院带药及随访期用药的依从性。

Objective With the physician training program and stroke clinic, the gap between clinical practice and the guideline for secondary prevention of ischemic stroke can been narrowed. Methods 305 patients with ischemic stroke were enrolled in a stroke clinic after their discharge from the hospital. Among the 305 patients, 87 were discharged before the institution of a physician training program （ pretraining group） and 218 after the institution （post-training group）. Their usage of antithrombotic agents, statins, non-standadized therapies and antihypertensive agents were compared at the time of discharge from the hospital and follow-up in the stroke clinic comparison was also made for the two groups of patients discharged before and after the physician training program. Results After the physician training program, implementation rates increased for antithrombotic agents （ 79.3% vs 93. 1%, P 〈 0. 01 ） and statins （ 19.5% vs 59.2% , P 〈0. 01 ）, using of non-standadized therapies decreased （47.1% vs 27. 5% , P = 0. 001 ）, but no change was found for using of antihypertensive agents （ 88.4% vs 94. 0% , P 〉 0. 05 ）. Comparing with the usage of medications at the time of discharge, the usage of antithrombotic agents and statins after discharge i, e. in the stroke clinic were further increased （for antithrombotics, in the pre- training group 79. 3% vs 86. 2%, P =0. 229, in the post-training group 93. 1% vs 94. 0%, P =0. 696; for statins, in the pre-training group 19. 5% vs 39. 1%, P = 0.005, in the post-training group 59. 2% vs 69. 7% , P = 0. 021 ）, while the usage of non-standadized therapies decreased further （ in the pre-training group 47.1% vs 17.2%, P 〈 0. 01, in the post-training group 27.5 % vs 14. 2%, P = 0. 001 ）. Implement of guideline at discharge influenced the compliance as the patients with high rates of usage of antithrombotic agents and statins at the time of discharge had also high rates of the usage of them at follow-up in the stroke clinic. Conclusions Physician training program increases the implement of the guideline for secondary stroke prevention and stroke clinic can improve the compliance with it. Usage of medications at the time of discharge influences the compliance with them during the follow-up period.