基层全科医生常见病诊疗能力现状与能力提升需求调查

Survey on the Status and Training Demands of Capabilities for Diagnosing and Treating Common Diseases of Primary Care General Practitioners in Hunan Province

背景建立基层卫生“守门人”制度,实现基层首诊、有序分流是落实分级诊疗制度的关键,而实施基层首诊的关键在于基层医疗卫生队伍能力建设。目的了解湖南省基层全科医生的常见病诊疗能力、转诊和循证实践能力现状,并了解其能力提升培训的需求,为开展以需求为导向的培训提供依据。方法2023年4—5月采用便利抽样的方法,选取近5年在中南大学湘雅医院参加过住院医师规范化培训或全科医师转岗培训的基层全科医生为调查对象,采用自行设计的调查问卷,包括基本信息、常见病诊疗能力的自我评价、循证实践能力的自我评价、能力提升的需求四个部分,利用“问卷星”平台进行数据收集,采用描述性分析方法对结果进行呈现和描述。结果共收集到来自湖南省各个地级市、自治州的337份有效问卷,其中128份来自社区卫生服务中心,209份来自乡镇卫生机构。乡镇卫生机构与社区卫生服务中心全科医生的性别、年龄、职称、基层工作年限、编制情况比较,差异均有统计学意义(P<0.05)。调查结果显示,75.1%(253/337)的基层全科医生认为自己具备基层常见病的诊疗能力;16.6%(56/337)的医生表示对某些疾病能力欠缺,这些疾病的前六位为抑郁[89.3%(50/56)]、压力性尿失禁[69.6%(39/56)]、痴呆[66.1%(37/56)]、脑卒中[53.6%(30/56)]、共病[51.8%(29/56)]、结核[46.4%(26/56)],结果在社区全科医生和乡镇全科医生中相似。71.8%(242/337)的基层全科医生表示对转诊规范和流程不够熟悉。73.0%(246/337)的医生表示对循证医学不够了解,85.8%(247/288)的基层全科医生表示循证医学在日常诊疗中的应用有限。77.2%(260/337)的医生对基层常见病的诊疗指南不够了解;90.8%(306/337)的医生在决策困难时一般不会选择查找指南,其原因主要是认为指南不能解决复杂的病情[50.0%(153/306)]、不清楚获取指南的操作[43.1%(132/306)]和来源[34.3%(105/306)]等;目前获取诊疗指南的渠道主要是微信公众号平台[72.5%(237/327)]、知网等数据库[50.2%(164/327)]。97.0%(327/337)的基层全科医生对能力提升的培训有需求,并提出应根据基层需求个性化开展培训[60.8%(205/337)];期望的途径主要是上级医院进修[71.3%(233/327)]和高诊疗能力的基层医疗卫生机构培训[56.3%(184/327)];期望的培训项目主要是常见疾病[78.0%(263/337)]和多病共存[69.4%(234/337)]的规范诊疗和转诊。结论湖南省基层全科医生中大多数认为自己具备基层常见病的诊疗能力,但对抑郁、压力性尿失禁、痴呆、脑卒中、共病、结核等疾病的诊疗能力相对欠缺;大多数医生规范转诊、循证医学实践、指南检索和应用等能力有待提高,提示这些可作为能力提升培训的侧重项目。基层全科医生对培训的需求较高,主要希望通过去高诊疗能力的卫生机构进修学习,对基层常见疾病和多病共存的规范诊疗、转诊培训有较高需求,具体的培训方式和内容可在广泛了解基层需求后根据实际情况制定。

Background First contact in the primary care setting and the development of a gatekeeping system are crucial for the implementation of a hierarchical medical system.Additionally,the implementation of first contact in the primary care setting depends on the serving capacities of primary care practitioners.Objective This study aims to assess the capabilities of primary care general practitioners in diagnosing and managing common diseases,referral practices,and evidence-based practice;and to explore their training needs to inform demand-driven training programs in Hunan Province.Methods From April to May 2023,a convenience sampling method was used to recruit primary care general practitioners who participated in the residency training or general practitioner transfer training at Xiangya Hospital,Central South University.A self-developed questionnaire consisting of four sections was used,covering basic characteristics,self-assessment of the capabilities for common diseases diagnosis and treatment,and evidence-based practice,and demands for capabilities improvement.Questionnaire Star platform was used to collect data,and descriptive analysis was used to present the results.Results A total of 337 valid questionnaires were collected from each prefecture-level city and autonomous prefecture in Hunan Province,with 128 coming from community health service centers and 209 from township health institutions.The differences in gender,age,professional title,years of service at the grassroots level,and staffing status between general practitioners in township health institutions and community health service centers are all statistically significant(P<0.05).The results show that 75.1%(253/337)of participants consider themselves competent in the diagnosis and treatment of common diseases;16.6%(56/337)of participants reported a lack of competence in certain diseases,with the top six including depression[89.3%(50/56)],stress incontinence[69.6%(39/56)],dementia[66.1%(37/56)],stroke[53.6%(30/56)],co-morbidities[51.8%(29/56)]and tuberculosis[46.4%(26/56)].These findings consistent between community and township respondents.Furthermore,71.8%(242/337)of participants reported being unfamiliar with referral practices.73.0%(246/337)of participants indicated limited knowledge of evidence-based practice,and 85.8%(247/288)of participants have limited use of evidence-based practice.Additionally,77.2%(260/337)of participants lacked sufficient knowledge of clinical practice guidelines;90.8%(306/337)of participants rarely consulted guidelines when facing decision-making difficulties,mainly because they felt guidelines could not address complex cases[50.0%(153/306)],were unclear on how to search for guidelines[43.1%(132/306)]and the resources available for retrieving guidelines[34.3%(105/306)];participants mainly obtain the guidelines through the WeChat official account[72.5%(237/327)]and databases such as the China National Knowledge Infrastructure[50.2%(164/327)].97.0%(327/337)of participants expressed a demand for training to improve their capabilities,suggesting that training should be tailored to the specific needs of primary care institutions[60.8%(205/337)];the preferred approaches are advanced training in higher-level hospitals[71.3%(233/327)]and primary care institutions with high diagnostic and treatment capabilities[56.3%(184/327)];the preferred training programs are on standardized treatment of common diseases[78.0%(263/337)]and multiple coexisting diseases[69.4%(234/337)].Conclusion The majority of primary care general practitioners in Hunan Province consider themselves competent in the treatment of common diseases,but some are relatively incompetent in diseases such as depression,stress urinary incontinence,dementia,stroke,co-morbidities and tuberculosis;the majority of participants need to improve their capabilities in standardized referral,evidence-based practice,retrieval and application of clinical practice guidelines,suggesting that these items could be focus of training.The primary care general practitioners have a high demand for training,they prefer to engage in advanced training in high level institutions,and training in standardized treatment of common diseases and multiple coexisting diseases is needed.The training programs should be individualized based on the demands of primary care institutions.