全科诊疗中慢性萎缩性胃炎管理现状调查研究

发布时间：2018-08-13 16:27

【摘要】：研究背景和目的目前国内慢性病防控形势严峻,根据《中国居民营养与慢性病状况报告(2015年)》,2012年全国居民慢性病死亡率高达533/10万,占总死亡人数的86.6%,慢性病的疾病负担占总疾病负担比例超过70%,慢性病对人们的生命和财产安全构成巨大威胁,它不但对患者的身心健康和生活产生严重的影响,并且由于久治不愈,给社会和患者的家庭造成沉重的负担。不健康饮食、久坐、饮洒、吸烟等不良生活方式是许多慢性病的根源,通过规范的管理,慢性病是可防可控的,然而慢性病和慢性病的管理并没有引起足够的重视,多种慢性病的管理亟待提高,比如慢性蒌缩性胃炎。早在1978年世界卫生组织就将慢性萎缩性胃炎定义为胃癌的癌前病变,胃癌在所有肿瘤中发病率和死亡率均居前列,给社会和家庭造成极大的痛苦和重担,然而国内关于慢性萎缩性胃炎的管理的研究却甚少。社区全科医生是慢性病管理的主要承担者,为了解社区慢性病特别是慢性萎缩性胃炎的管理现状,我们分别设计了针对社区全科医师和社区居民的调查问卷,并对社区全科医师进行访谈,在对问卷和访谈结果进行统计学分析后,根据分析结果以全科理念提出相关的建议,为社区全科医师更好的开展慢性萎缩性胃炎管理提供参考。研究方法本论文主要运用文献法、问卷调查法和访谈法对社区慢性病和慢性萎缩性胃炎管理现状进行调查和研究。在2016年10-11月查考有关慢性病管理和慢性萎缩性胃炎的文献并设计调查问卷,调查问卷分为居民版和医师版两部分。2016年12月-2017年2月在济南市北村和燕山社区及社区卫生服务中心等地发放调查问卷,并与填写问卷的所有社区医师进行访谈,所有被调查者均自愿参加。共发放居民版调查问卷650份,回收有效问卷637份,回收率98.0%;医师版调查问卷发放26份,回收有效问卷26份,回收率100%。以调查问卷为提纲,与所有填写调查问卷的26名医师进行访谈。如实记录访谈内容,并在调查结束后进行整理和汇总。使用Epidata3.1软件建立数据库,采用双人双机重复录入调查问卷,确保数据的准确性;使用SPSS19.00统计分析软件并运用描述性统计(Descriptive Statistics)、卡方分析(Chi—Square Analysis)和二元 Logistic 回归分析(Logistic Regression Analysis)等统计方法对数据进行整理与分析。结果1.社区居民对慢性病及其相关知识的认识有43.3%社区居民不了解或不太了解什么是慢性病,而86.7%的居民不了解或者不太了解慢性病管理及相关知识;居民对糖尿病和高血压的了解较多,对其他慢性病了解较少;社区居民获得相关慢性病知识的渠道以网络和媒体为主,从卫生服务中心获得的慢性病相关知识所占比例较低。年龄50岁、明确自己患有慢性病的居民对慢性病和慢性病管理的相关知识了解更多。2.社区居民对慢性萎缩性胃炎及其相关知识的认识有84.9%居民不太了解或从未听说过慢性萎缩性胃炎,对慢性萎缩性胃炎防治相关知识的知晓率更低,但居民对慢性萎缩性胃炎和胃癌的关系的认识度却较高;有85.6%的居民从未做过胃镜检查,居民对慢性萎缩性胃炎的认识低于对慢性病总体的认识。3.居民对社区卫生服务中心的认可程度及首诊医院的选择有39.5%的居民对社区卫生服务中心提供的医疗服务非常认可或比较认可,46.3%的居民认为社区提供的医疗服务一般;仅有25.0%的居民选择社区卫生服务中心为首诊医疗场所,而59.6%的居民选择去综合性医院,其余15.4%选择暂不就诊。可见居民对社区卫生服务中心的认可度和信任度较低。4.社区全科医师慢性病管理工作现状社区全科医师在慢性病管理中所管理的慢性病主要是糖尿病和高血压,其它慢性病管理开展较少,全科医生在慢性病管理中开药占据的工作量最大,健康教育、健康档案建立,随访等都有开展,但是力度不够;57.6%的全科医生认为目前慢性病管理的效果不好或者一般,主要原因是工作量大,难以实施细化及个体化管理,且规范管理的慢性病种类少。有7.7%和34.6%的社区全科医生认为慢性病管理的效果非常好和比较好,主要原因是目前重点管理的慢性病已经取得较好的效果。社区医师认为导致慢性病管理困难的原因依次是:工作量大、社会不重视、缺乏相应政策、患者不认可、缺乏慢性病相关培训。而政府政策大力支持、提高相关待遇、提高社会认可度等有利于提高社区全科医师慢性病管理的积极性。5.社区全科医师对慢性萎缩性胃炎规范管理开展的建议。目前社区未开展慢性萎缩性胃炎的规范管理,原因为慢性萎缩性胃炎不是重点监管的慢性病,社区缺乏慢性萎缩性胃炎的常用的治疗设备,转诊制度不完善,全科医师慢性萎缩性胃炎管理的知识及技能有待提高。因此开展慢性萎缩性胃炎的规范管理应从政策支持、社区硬件建设、转诊制度完善、医师培训等几个方面努力。结论1.目前济南市社区慢性病管理中高血压和糖尿病管理较好,其它慢性病管理效果一般,居民特别是年轻人和非慢性病患者对慢性病的认识和重视度不够,居民对慢性萎缩性胃炎相关知识知晓率非常低。2.济南市社区未开展规范的慢性萎缩性胃炎的管理,主要原因为:社区全科医生较少,现有慢性病管理的工作量已经非常大;社区缺乏慢性萎缩性胃炎的诊疗设备,而转诊制度又不完善;社区医师对慢性萎缩性胃炎管理的知识不熟悉。3.要有效的开展慢性萎缩性胃炎的规范管理需要以下几方面的共同努力:(1)相关部门政策引导和支持:将慢性萎缩性胃炎纳入慢性病管理及医保范畴,积极引导患者到社区卫生服务中心就诊。(2)社区硬件建设的提升:社区引进消化系统常用的诊疗设备和增加常用治疗药物种类,加大预防保健和健康教育的投入和力度。(3)全科医生慢性病管理的水平的提高:组织社区全科医师学习慢性萎缩性胃炎防治的相关知识,提高全科诊疗理念和慢性病管理水平。4.通过对慢性萎缩性胃炎的规范管理,可以从预防慢性萎缩性胃炎的发生,积极治疗慢性萎缩性胃炎患者,规律内镜检查和病理随访等方面来减少胃癌的发生和提高胃早癌的检出率。
[Abstract]:Background and Objective The current situation of chronic disease prevention and control in China is grim. According to the Report on the Status of Nutrition and Chronic Diseases of Chinese Residents (2015), the mortality rate of chronic diseases in China reached 5.33/100,000 in 2012, accounting for 86.6% of the total deaths, and the burden of chronic diseases accounted for more than 70% of the total disease burden. It not only has a serious impact on the physical and mental health and life of the patients, but also imposes a heavy burden on the society and the families of the patients because of the long-term treatment. Unhealthy diet, sedentary, drinking and smoking are the root causes of many chronic diseases. Chronic diseases can be prevented and controlled by standardized management. As early as 1978, the World Health Organization (WHO) defined chronic atrophic gastritis as precancerous lesion of gastric cancer. The incidence and mortality of gastric cancer in all cancers are in the forefront, to society and families. In order to understand the management status of chronic diseases in the community, especially chronic atrophic gastritis, we designed questionnaires for community general practitioners and community residents respectively. After statistical analysis of the results of questionnaires and interviews, some suggestions were put forward based on the results of the analysis to provide reference for community general practitioners to better carry out the management of chronic atrophic gastritis. Investigation and Study on the management status of STDs and chronic atrophic gastritis. Literatures on chronic disease management and chronic atrophic gastritis were investigated and questionnaires were designed from October to November, 2016. The questionnaires were divided into residents'and doctors' editions. A total of 650 residents'questionnaires were sent out and 637 valid questionnaires were returned with a recovery rate of 98.0%. 26 doctors' questionnaires were sent out and 26 valid questionnaires were returned with a recovery rate of 100%. Twenty-six physicians were interviewed by questionnaires.The interviews were recorded truthfully and collected at the end of the survey.The database was established by using Epidata 3.1 software and the questionnaires were duplicated by two persons and two computers to ensure the accuracy of the data.SPSS19.00 statistical analysis software was used and descriptive statistics was used. Chi-Square Analysis and Logistic Regression Analysis were used to collate and analyze the data. Results 1. 43.3% of the community residents did not know or did not know what chronic diseases were, while 86.7% did not know or did not know much about them. Understanding of chronic disease management and related knowledge; Residents know more about diabetes and hypertension, less about other chronic diseases; Community residents access to relevant knowledge of chronic diseases mainly through the network and the media, the proportion of chronic disease-related knowledge from health service centers is lower. Age 50 years old, clear that they have chronic diseases. Residents know more about chronic diseases and management of chronic diseases. 2. 84.9% of the residents in the community do not know or have never heard of chronic atrophic gastritis. The awareness rate of prevention and treatment of chronic atrophic gastritis is lower, but the residents do not know about chronic atrophic gastritis and gastric cancer. 85.6% of the residents had never undergone gastroscopy, and their understanding of chronic atrophic gastritis was lower than that of the general understanding of chronic diseases. 3. The recognition of community health service centers and the choice of first-visit hospitals were highly recognized by 39.5% of the residents. 46.3% of the residents believed that the community provided general medical services; only 25.0% of the residents chose community health service centers as the first place of medical treatment; 59.6% of the residents chose to go to general hospitals; the remaining 15.4% chose not to see a doctor. Current situation of chronic disease management in community general practitioners is mainly diabetes and hypertension in chronic disease management, other chronic disease management is less carried out, general practitioners in the management of chronic diseases take up the largest workload, health education, health records, follow-up and so on, but not enough; 7.7% and 34.6% of the community general practitioners believed that the effect of chronic disease management was very good and better, mainly because of the heavy workload, difficult to implement detailed and individualized management, and the lack of standardized management of chronic diseases. Community physicians believe that the causes of chronic disease management difficulties are: heavy workload, social neglect, lack of corresponding policies, patients do not recognize, lack of chronic disease-related training. Community general practitioners'suggestions on the standardized management of chronic atrophic gastritis. Currently, there is no standardized management of chronic atrophic gastritis in the community. The reason is that chronic atrophic gastritis is not a chronic disease under the key supervision, the community lacks the commonly used treatment equipment for chronic atrophic gastritis, and the referral system is imperfect. The knowledge and skills of general practitioners in the management of chronic atrophic gastritis need to be improved. Therefore, the standardized management of chronic atrophic gastritis should be carried out from the following aspects: policy support, community hardware construction, perfect referral system, doctor training and so on. The effect of STD management is general. Residents, especially young people and non-chronic patients, do not pay enough attention to chronic diseases. Residents'awareness of chronic atrophic gastritis is very low. 2. Jinan community did not carry out standardized management of chronic atrophic gastritis. The main reasons are: fewer community general practitioners, the existing management of chronic diseases. The workload is already very large; the community lacks the chronic atrophic gastritis diagnosis and treatment equipment, and the referral system is not perfect; the community physicians are not familiar with the knowledge of chronic atrophic gastritis management. 3. To effectively carry out the standardized management of chronic atrophic gastritis requires the following joint efforts: (1) relevant departments to guide and support policy: Chronic atrophic gastritis is included in the category of chronic disease management and medical insurance, and actively guide patients to the community health service center. (2) Improvement of community hardware construction: community introduction of digestive system commonly used diagnostic and treatment equipment and increase the types of commonly used treatment drugs, increase the investment and intensity of preventive health care and health education. (3) General practitioners chronic disease management. Improvement of physical level: Organizing community general practitioners to learn the knowledge of prevention and treatment of chronic atrophic gastritis, improving the concept of general practice and management of chronic diseases. 4. Through standardized management of chronic atrophic gastritis, we can prevent the occurrence of chronic atrophic gastritis, actively treat chronic atrophic gastritis patients, regular endoscopy and regular endoscopy. Pathological follow-up and other aspects to reduce the incidence of gastric cancer and improve the detection rate of gastric cancer.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R573.32;R197.61

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