北京朝阳区基层全科医生的变应性鼻炎知识知晓与诊疗情况

Allergic Rhinitis-related Knowledge,Diagnosis and Treatment among General Practitioners in Chaoyang District,Beijing

背景 变应性鼻炎(AR)是高发的慢性非传染性疾病,目前国内关于AR知晓和治疗的研究主要来自耳鼻喉专科,针对国内基层全科AR诊疗的建议及基层全科医生对AR知识知晓、诊疗情况的相关研究较少。目的 了解基层全科医生AR知识知晓与诊疗情况。方法 2020年8—9月,采用简单随机抽样法于北京市朝阳区抽取21家社区卫生服务机构的432例全科医生为研究对象。调查问卷结合《变应性鼻炎诊断和治疗指南(2015年,天津)》(简称我国2015 AR指南)和Allergic Rhinitis and Its Impact on Asthma(ARIA)Guidelines:2010 Revision及其2016修订版的指南设计,咨询专家及预调查后完善问卷,内容涉及研究对象基本情况、AR知识知晓、诊疗行为、培训和支持需求等。结果 432份问卷中共回收有效问卷383份(88.7%)。AR典型症状、诊断、治疗原则、一线药物类别及指南推荐疗程等题目全部回答正确的基层全科医生仅占0.8%(3/383),32.4%(124/383)的全科医生了解AR指南,其了解的指南包括我国2015 AR指南、ARIA指南等,学习来源包括好医生、丁香园、微信等网络继续教育及相关培训。59.8%(229/383)的医生接诊呼吸道疾病时每次会与AR鉴别;37.1%(142/383)的医生每次都进行环境控制指导,17.8%(68/383)的医生每次向患者推荐鼻腔冲洗,49.4%(189/383)的医生不会给患者推荐免疫治疗,13.1%(50/383)的医生会转诊AR患者而不对其诊疗,17.5%(67/383)的医生表示所在机构提供全部(4类)一线AR治疗用药;75.7%(290/383)的医生未在2019年参加过任何AR相关培训;91.7%(266/290)的医生需要AR相关培训,95.6%(366/383)的医生认为AR患者应该在社区进行规范治疗。多因素Logistic逐步回归分析显示,学历硕士及以上[OR(95%CI)=2.790(1.057,7.366)]、掌握AR患者的健康教育知识[OR(95%CI)=3.537(2.015,6.209)]的医生遇到呼吸道症状时更倾向考虑AR的鉴别诊断,掌握AR患者的健康教育知识[OR(95%CI)=4.397(0.534,1.576)]的医生更倾向对患者进行环境控制行为指导,了解鼻腔冲洗操作[OR(95%CI)=6.592(3.038,14.306)]的医生倾向推荐鼻腔冲洗,了解免疫治疗[OR(95%CI)=1.881(1.087,3.254)]、治疗原则答题正确[OR(95%CI)=128.330(16.628,990.402)]或所在机构提供部分或全部实验室检查项目[OR(95%CI)=2.210(1.299,3.760)]的医生更倾向推荐免疫治疗。结论 朝阳区基层全科医生AR知识和指南知晓率较低,诊疗行为欠缺规范性,但其对继续学习及在基层展开AR规范治疗的态度较为积极。基层全科医生AR知识知晓及指南掌握程度越高越能促进其诊疗行为的规范性,故而应加强基层全科医生培训,制定适宜基层应用的AR指南,为基层进行AR规范治疗提供支持。

Background Allergic rhinitis(AR) is a highly prevalent chronic non-communicable disease. The research on the understanding and treatment of AR in China is mainly in otorhinolaryngology specialists,but rarely in general practitioners(GPs)in primary care. And recommendations on the diagnosis and treatment of AR in primary care are also insufficient.Objective To explore the understanding of AR and diagnosis and treatment capacities related to AR in GPs in primary care.Methods By use of simple random sampling,432 GPs from 21 community health service organizations in Beijing’s Chaoyang District were chosen between August and September 2020. The questionnaire was combined with the Guidelines for the Diagnosis and Treatment of Allergic Rhinitis(Tianjin,2015)(China 2015 AR Guidelines)and Allergic Rhinitis and Its Impact on Asthma(ARIA)Guidelines:2010 Revision,and its 2016 annual revision,and refinement of the questionnaire after consultation with experts and pre-survey. The information obtained from the questionnaire included basic information about the subjects,understanding level,diagnostic and therapeutic behaviors,training, and support needs regarding AR,et al. Results The 383(88.7%)of the 432 questionnaires were finally returned. Only 0.8%(3/383)of the GPs correctly responded to all of the questions on typical AR symptoms,diagnosis,treatment philosophies,first-line drug classes,and regimens suggested by guidelines. Guidelines for AR,including China 2015 AR Guidelines and ARIA Guidelines,were known to 32.4%(124/383)of the GPs,Web-based continuing education such as www.haoyisheng.com,www.dxy.cn and WeChat and related training. When treating each patient with a respiratory illness,the prevalence of GPs differentiating AR from others,providing recommendations on environmental control,suggesting nasal rinsing,recommending other treatments instead of immunotherapy,and referring the patient to the specialty department without any treatment,was 59.8%(229/383),37.1%(142/383),17.8%(68/383),49.4%(189/383),and 13.1%(50/383),respectively. In terms of pharmacological treatment,17.5%(67/383)of GPs said their hospital offered all four classes of first-line AR medications. As for AR-related training,75.7%(366/383)of the GPs reported not having taken any AR-related training in 2019;and 91.7%(266/290)needed the training. And 95.6%(290/383)of the GPs said AR should be handled standardizedly in the community. A multivariate stepwise regression Logistic analysis revealed that when encountering patients with respiratory symptoms,GPs with a master’s degree or higher[OR(95%CI)=2.790(1.057,7.366)]and a good grasp of AR-related health knowledge[OR(95%CI)=3.537(2.015,6.209)]were more likely to make a differential diagnosis of AR from other illnesses,GPs with a good grasp of AR-related health knowledge [OR(95%CI)=4.397(0.534,1.576)]were more likely to offer patients guidance on environmental control behaviors,GPs who were familiar with nasal irrigation procedures[OR(95%CI)=6.592(3.038,14.306)]were more likely to recommend nasal irrigation,and GPs knowing about immunotherapy[OR(95%CI)=1.881(1.087,3.254)],accurately answering questions on the principles of treatment[OR(95%CI)=128.330(16.628,990.402)]or their institution providing some/all laboratory testing services[OR(95%CI)=2.210(1.299,3.760)]were prone to recommend immunotherapy. Conclusion Despite their low awareness levels of AR expertise and guidelines,and unsatisfied practice standardization,GPs in primary care in Chaoyang District demonstrated proactive attitude towards continuing education and carrying out standardized AR treatment in primary care. As high awareness levels of AR-related knowledge and guidelines promote the practice standardization,relevant trainings for GPs in primary care should be strengthened,and AR-related guidelines applicable to primary care should be developed,which can provide support for the standardization of AR treatment at the primary care level.