中国11个城市社区全科医师降压治疗观念及高血压管理现状调查

Survey on concept of antihypertensive therapy and hypertension management among general practitioners in community health centers in 11 cities of China

目的了解社区卫生服务中心(CHC)全科医师的高血压诊疗及患者管理情况。方法以全国东部、西部、南部、北部地区划分,在全国11个城市按照分层抽样的方法,从中选取350家CHC参与该项研究。每家CHC选取一名全科医师,于2018年3月12日至4月20日展开调查,发放并收集问卷。问卷内容包括全科医师接诊中高血压患者比例、治疗达标率,降压药物及方案使用情况,患者用药依从性、随访、家庭自测血压等情况,以及分级诊疗制度对CHC的影响。结果收回有效问卷350份。在全科医师接诊的患者中,46%(30%,60%)为高血压患者,41%(40%,55%)为一级高血压,42%(40%,50%)为二级高血压;72%(60%,80%)患者合并其他疾病,如血脂异常、糖尿病、冠心病等。全科医师降压治疗以西药为主[90%(82%,100%)],最常用的降压药为钙通道阻滞剂[46%(30%,60%)],降压治疗方案以单药[35%(25%,50%)]或自由联合[50%(40%,60%)]为主,选择降压药物时首先考虑平稳[(9.1±0.8)分]、长效[(9.0±0.9)分]和达标率高[(8.7±1.1)分]的降压药物,治疗达标率为61%(50%,75%)。规律随访、坚持血压自测和长期规律服药患者比例分别为60%(50%,70%)、51%(40%,70%)和65%(50%,70%),影响患者依从性的主要因素为患者既往心血管病史[(8.4±1.1)分]和对疾病的认知[(8.3±1.1)分]。全科医师认为分级诊疗制度的积极影响包括有助于和患者建立更加紧密的关系[62.6%(219/350)]和社区优惠的报销政策提高了患者的依从性[58.6%(205/350)];而CHC面临的挑战有患者较高的期望值[52.8%(185/350)]和门诊量增加[52.6%(184/350)]。检查设备不齐全[68.3%(239/350)]、配药不足[52.3%(183/350)]等问题制约着CHC的发展,同时全科医师的医术水平[51.7%(181/350)]也有待提高。结论高血压患者约占全科医师接诊比例的一半,且多合并心脑血管疾病或危险因素,患者长期治疗依从性及血压自我管理情况等均有待进一步提高。

Objective To survey the status of antihypertensive therapy knowledge and hypertension management among general practitioners in community health centers(CHCs)in China.Methods Based on the eastern,western,southern and northern regions of the country,350 CHCs were selected from 11 cities across the country with stratified sampling method for study sites,and one general practitioner was selected from each CHC.The questionnaire survey was conducted from March 12 to April 20,2018 among 350 participants.The content of the questionnaire included the proportion of hypertensive patients in the consultation,treatment target rate,antihypertensive drugs and protocol,the medication compliance,follow-up,blood pressure self-measurement,and the impact of hierachical medical system on CHC.Results Total 350 valid questionnaires were recovered.The survey showed that:(1)Among the patients treated by general practitioners,46%(30%,60%)were hypertensive patients including 41%(40%,55%)with primary hypertension and 42%(40%,50%)with secondary hypertension;72%(60%,80%)of the patients had comorbidities,including dyslipidemia,diabetes,and coronary heart disease.(2)Western medicine was the main antihypertensive treatment[90%(82%,100%)],calcium channel blockers were the most commonly used antihypertensive drug[46%(30%,60%)],the therapeutic protocol was mainly single agent[35%(25%,50%)]or free combination[50%(40%,60%)];the stable(9.1±0.8),long-acting(9.0±0.9)and high standard reaching rate(8.1±1.1)antihypertensive drugs were first considered,and the standard reaching rate of hypertension treatment was 61%(50%,75%).(3)The regular follow-up rate,adherence to blood pressure self-test rate and long-term regular medication rate was 60%(50%,70%),51%(40%,70%)and 65%(50%,70%),respectively.The factors affecting patients′compliance were history of cardiovascular diseases(8.4±1.1)and patients′cognition of disease(8.3±1.1).General practitioners believed that the positive effects of the hierarchical diagnosis and treatment system include helping to establish a closer relationship with patients[62.6%(219/350)]and improving patient compliance for community preferential reimbursement policies[58.6%(205/350)].The challenges faced by CHC included higher patient expectations[52.8%(185/350)]and increased outpatient visits[52.6%(184/350)].Insufficient diagnostic equipment[68.3%(239/350)],inadequate dispensing[52.3%(183/350)]and other issues restricted the development of CHC,and the clinical competence of general practitioners[51.7%(181/350)]need to be improved.Conclusion Patients with hypertension account for about half of the total number of visits in community health service centers,and most of them are comorbid with cardiovascular and cerebrovascular diseases or risk factors.The long-term treatment compliance and self-management of blood pressure need to be further improved.