《早产临床诊断与治疗指南(2014)》实施现况调查与分析

Investigation and analysis of the implementation status of“Diagnosis and therapy guideline of preterm birth(2014)”

目的了解一线产科医师执行《早产临床诊断与治疗指南(2014)》(简称《指南》)的实际情况,为《指南》的进一步更新、补充提供参考。方法本研究围绕早产防治的突出问题,自行设计结构式调查问卷,并由《指南》起草专家团队确定,于2021年10—11月采用横断面研究方法对产科医师,包括江苏省医学会围产医学分会委员、中华医学会妇产科学分会产科学组成员,就《指南》执行现状进行问卷调查,以《指南》推荐作为标准答案计算执行率,共回收有效问卷328份。问卷总分为12分,以得分7分为界值,分为低执行力组(<7分)和高执行力组(≥7分),比较两组在医院等级、医师职称等基线信息方面的差异。结果328例产科医师的得分为(7.6±1.6)分,其中,高执行力组250例(76.2%,250/328),低执行力组78例(23.8%,78/328)。对宫缩抑制剂短疗程使用[执行率为97.0%(318/328)]、早产儿出生后晚断脐[执行率为87.8%(288/328)]、胎膜完整的早产患者是否使用抗生素[执行率为86.6%(284/328)]回答正确率均超过80%,执行率良好。多因素logistic回归分析显示,医院等级、职称是《指南》执行优劣的独立影响因素(P均<0.05),二级医院比三级医院得分低、执行力差(OR值=0.42,95%CI为0.23~0.77),正高职称比初级职称得分高、执行力好(OR值=5.33,95%CI为2.35~12.07)。在回答"您所在医院早产儿能够存活的孕周"问题时,回答22周能存活者仅占3.4%(11/328),回答28周能存活者占比最高,为44.5%(146/328);三级医院能存活的早产儿孕周早于二级医院(P<0.05),正高职称者回答能存活的早产儿孕周早于低级职称者(P<0.05)。结论产科医师对《指南》总体执行情况良好,对部分指南推荐条款的认识还有待提高,未来需加强对基层医院和初级职称医师的培训。

Objective To understand the actual situation of the implementation of“Diagnosis and therapy guideline of preterm birth(2014)”,“Guideline”for short,by front-line obstetricians,and to provide reference for the further update and supplement of the“Guideline”.Methods This study designed a structured questionnaire for the prominent problems in the prevention and treatment of preterm birth,which was determined by the expert team drafting the“Guideline”.In October to November 2021,a cross-sectional survey was conducted among obstetricians,including members of the Perinatal Medicine Branch of Jiangsu Medical Association and the Obstetrics Subgroup,Chinese society of Obstetrics and Gynecology,Chinese Medical Association,on the implementation status of the“Guideline”.The recommendations of the“Guideline”were used as standard answers to determine the implementation rate.A total of 328 valid questionnaires were collected.The total score of the questionnaire was 12 points.The questionnaire was divided into low executive ability group(<7 points)and high executive ability group(≥7 points)with a score of 7 as the threshold value,and the differences in baseline information such as hospital grade and professional title between the two groups were compared.Results The score of 328 obstetricians was(7.6±1.6)points,including 250(76.2%,250/328)in the high execution group and 78(23.8%,78/328)in the low execution group.The execution rates of“the use of uterine contraction inhibitors for short courses”[97.0%(318/328)],“late umbilical cord breakage after birth of premature infants”[87.8%(288/328)]and“should preterm patients with intact membranes be treated with antibiotics”[86.6%(284/328)]were all over 80%,indicating good implementation.Multiple logistic regression analysis showed that hospital grade and professional title were independent factors influencing the performance of the“Guideline”(all P<0.05),and secondary hospitals had lower scores and worse execution than tertiary hospitals(OR=0.42,95%CI:0.23-0.77;P=0.005).Senior titles had higher scores and better execution than junior titles(OR=5.33,95%CI:2.35-12.07;P<0.001).When answering the question“gestational week at which premature infants could survive in your hospital”,only 3.4%(11/328)answered 22 weeks,and 44.5%(146/328)answered 28 weeks,accounted for the highest proportion.The gestational week of surviving premature infants in tertiary hospitals was earlier than that in secondary hospitals(P<0.05).The gestational week of surviving premature infants answered by senior titles was earlier than that of junior titles(P<0.05).Conclusions Obstetricians generally have a good implementation of the“Guideline”,and their understanding of some recommended clauses in the guidelines needs to be improved.In the future,training of primary hospitals and physicians with junior titles should be strengthened.