目的 调查基层医院慢性心力衰竭患者的治疗现状及相关影响因素.方法 于2015年6月对聊城市各县区县级医院和乡镇医院进行调查,纳入各县的县级医院1个,共纳入7个县级医院,并在各县内采用随机数字表法抽取2个乡镇医院,共纳入14个乡镇医院.以调查当天的值班医生为调查对象,调查患者为所调查医生近3个月治疗的心力衰竭住院患者.自行设计医生调查问卷,包括性别、年龄、获得医师资格年限、对心力衰竭指南的态度、是否取得心内科医师资格、缺乏心力衰竭指南的学习资料、医生对心力衰竭指南的掌握程度、医院的硬件设施以及是否重视心力衰竭患者的规范化治疗.统计调查医生近3个月治疗的心力衰竭住院患者的病历,包括患者基本信息、症状、体征、辅助检查结果及出院时心力衰竭药物的应用情况.结果 共调查医生64名,其中县级医院26名,乡镇级医院38名.两者性别、年龄、获得医师资格年限、对心力衰竭指南的态度得分比较,差异均无统计学意义(P>0.05).县级医院取得心内科医师资格所占比例、有足够心力衰竭指南学习资料所占比例、医生对心力衰竭指南的掌握程度得分、医院得分均高于乡镇级医院(P<0.05).乡镇级医院纳入患者49例,县级医院290例.两者舒张压、高血压、冠心病、心律失常、心界扩大、脑钠肽(BNP)检查率、肌酐检查率、电解质检查率、心脏超声检查率、纽约心功能分级比较,差异均有统计学意义(P<0.05).339例患者中,应用强心剂154例(45.4%),利尿剂268例(79.0%),螺内酯201例(59.3%),β-受体阻滞剂130例(38.3%),血管紧张素转化酶抑制剂(ACEI)/血管紧张素受体拮抗剂(ARB)150例(44.2%).不同级别医院的患者强心剂、利尿剂、螺内酯、β-受体阻滞剂、ACEI/ARB使用率比较,差异均有统计学意义(P<0.05).结论 基层医院未能按照指南进行规范化药物治疗心力衰竭患者,可能与乡镇级医院硬件设施差、学习资料缺乏、医院重视不够有关.县级医院具备治疗心力衰竭条件,但药物应用仍不规范.%Objective To investigate the status and associated factors of the treatment for chronic heart failure(CHF) in grassroots medical institutions of Liaocheng.Methods We conducted this survey in June 2015.Using random sampling,from 7 counties of Liaocheng,we selected totaled 7 county-level hospitals(1 was selected from each),and 14 township hospitals (2 were selected from each).We enrolled the doctors on the duty in these hospitals on the survey day and the CHF patients managed by them in the past 3 months.Using a self-developed Doctor Data Questionnaire,we collected the data about sex,age, years with the physician certification,attitude toward the guidelines for CHF,cardiovascular physicians or not,amount of study materials about CHF,degree of mastering the guidelines for CHF,status of hospital hardware facilities,attitude of the hospital toward standardized treatment for CHF.We collected the data of the CHF patients by reviewing their medical records,including the demographic data,clinical data(symptoms,signs,auxiliary examination results and use of anti-CHF drugs at the time of discharge).Results Totaled 64 doctors were enrolled,26 of them from county-level hospitals,and other 38 from township hospitals.Both groups had no significant differences in gender,age,years with physician qualification and attitude toward heart failure guideline(P>0.05),but higher percentage of doctors from county-level hospitals were cardiovascular physicians, adequacy of study materials about CHF guidelines,scored higher in mastering the CHF guidelines(P<0.05).Comprehensive scores of county-level hospitals were higher compared with township hospitals(P<0.05).Totaled 339 patients were enrolled, 290 them from county-level hospitals,and other 49 from township hospitals.The diastolic pressure value,prevalence of hypertension,coronary heart disease,arrhythmia,and enlargement of the heart,rates of serum BNP,creatinine,and electrolyte measurement,rate of undergoing echocardiography,and status of NYHA class were all different between the two groups(P<0.05).In terms of medication,154(45.4%) used cardiac stimulants,268(79.0%) used diuretics,201 (59.3%) used spironolactone,130(38.3%) used beta-blockers,and 150(44.2%) used ACEI/ARB.The use rate of cardiac stimulants,diuretics,spironolactone,beta-blockers,or ACEI/ARB differed significantly between the two groups (P<0.05).Conclusion CHF patients from township hospitals in Liaocheng could not receive standardized treatment,which may be associated with poor hardware facilities,doctors' lack of study materials,and hospitals paying insufficient attention to the treatment.In contrast,the county-level hospitals have conditions for treating CHF,but the medication prescribed for patients was not standardized.
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