上海市不同区域帕金森病患者剂末现象的调查分析

Analysis of the wearing-off phenomenon in Parkinson’s disease patients from various districts of Shanghai

目的对上海市帕金森病剂末现象问卷研究组(Shanghai Research Alliance of Parkinson’s Disease wearing-off questionnaire,shapd-woq)研究纳入的上海帕金森病(parkinson’s disease,PD)患者按照所属行政区进行分类,以探究不同区域患者剂末现象(wearing-off phenomenon,WO)发生情况的差异。方法提取shapd-woq研究的数据库中2017年9月—2018年6月于上海市16个行政区的11家三级医院和27家二级医院就诊的PD患者资料,进行区域间差异分析。观察、比较各行政区患者的性别、年龄、发病年龄、病程和Hoehn&Yahr(H&Y)分期,以及抗PD治疗时间、左旋多巴(levodopa,LD)和左旋多巴等效剂量(L-dopa equivalent dosage,LED)日用药剂量、多巴丝肼使用比例。采用中文版剂末现象9项(CWOQ-9)问卷作为患者WO的自评量表,比较各行政区问卷分值和相关症状波动的发生情况;临床医师通过询问病史和查询病例报告表(CRF)以诊断患者是否发生WO;采用Kappa检验分析患者自评为WO阳性率与临床医师诊断患者为WO阳性率的一致性。结果1274例患者被纳入本研究。患者的总体发病年龄为(64.11±10.00)岁,总体H&Y分期为(2.29±0.88)期,两者在各行政区间的差异均有统计学意义(F=2.596、3.599,P=0.001或<0.001)。患者总体LD日用药剂量为(6.52±4.19)mg/(kg·d),总体LED日用药剂量为(8.02±4.74)mg/(kg·d);1274例患者中共有1112例(87.3%)使用多巴丝肼治疗,上述指标在各行政区间的差异均有统计学意义(F=2.724、2.834,χ^(2)=35.769。P<0.001或=0.002)。临床医师诊断患者为WO的总体阳性率为56.4%(719/1274),患者使用CWOQ-9问卷自评为WO的总体阳性率为76.3%(972/1274),两者在各行政区间的差异均有统计学意义(χ^(2)=91.559、95.645,P值均<0.001)。Kappa检验结果显示,患者自评为WO的阳性率与临床医师诊断患者为WO的阳性率的一致性欠佳(κ=0.475)。患者CWOQ-9问卷自评的阳性分值总体为3.00(1.00,4.00)分,各行政区间分值的差异有统计学意义(F=3.660,P<0.001)。各行政区各症状波动的发生率不尽相同,杨浦区发生率最高的为震颤(52.0%),其余各行政区发生率相对最高的为运动缓慢。结论上海市各行政区PD患者的临床特点、用药情况及WO阳性率存在差异,临床医师的WO诊断阳性率与患者自评阳性率的一致性也存在区域间差异,故应有重点地加强部分行政区PD规范化管理的培训与质量控制,使上海市各行政区患者得到均质化的诊疗服务。

Objective To analyze the difference in the wearing-off phenomenon(WO)among patients with Parkinson disease(PD)from various districts of Shanghai in the study of Shanghai Research Alliance of Parkinson Disease Wearing-off questionnaire(shapd-woq).Methods Clinical data of PD patients treated in 11 third-level hospitals and 27 second-level hospitals in 16 districts of Shanghai from September 2017 to June 2018 were collected,and regional classification analysis was carried out.The gender,age,age of onset,course of disease,H&Y stage,anti-PD treatment time,daily doses of levodopa(LD)and L-dopa equivalent dose(LED),and the use proportion of madopar were compared among patients from different districts.The Chinese version of the 9-item wearing-off questionnaire(CWOQ-9)was used as self-rating scale of patients,and the scores of the questionnaire and the occurrence of related symptoms were compared in different regions.WO was identified by clinicians through medical history and case report form(CRF).Kappa test was used to analyze the consistency of WO positive rate between patient self-assessment and clinician assessment.Results A total of 1274 patients were included in this study.The mean age of onset was(64.11±10.00),and the mean H&Y stage was stage 2.29±0.88.There were significant differences in the age of onset and H&Y stage among various districts(F=2.596,3.599,P<0.001).The mean daily dose of LD and LED was(6.52±4.19)mg/(kg·d)and(8.02±4.74)mg/(kg·d),respectively.Madopar was used in 87.3%patients(1112/1274).There were significant differences in the daily dose of LD,daily dose of LED and use proportion of madopar among various districts(F=2.724,2.834,χ^(2)=35.769,P<0.001 or P=0.002).The prevalence of WO identified by clinician assessment and patient self-assessment was 56.4%(719/1274)and 76.3%(972/1274),respectively.There were significant differences in the prevalence of WO identified by clinician assessment and patient self-assessment among various districts(χ^(2)=91.559,95.645,P<0.001).Kappa test showed poor consistency of WO positive rate between patient self-assessment and clinician assessment(κ=0.475).The overall positive score of CWOQ-9 self-evaluation was 3.00(1.00,4.00),which was significantly different among various districts(F=3.660,P<0.001).The incidence of symptom fluctuation varied in the 16 districts of Shanghai.The highest incidence in Yangpu District was tremor(52.0%),and the highest incidence in other regions was bradykinesia.Conclusion There are differences in the clinical characteristics,medication use and the incidence of WO in PD patients from different regions of Shanghai.There are also regional differences in the consistency between the WO diagnosis rate of clinicians and the positive rate of patient self-assessment.It is necessary to further strengthen the quality control and doctor training for PD standardized management in order to achieve homogenized diagnosis and treatment of PD.