US NATIONAL SURVEY OF PHYSICIAN PRACTICES FOR THE SECONDARY AND TERTIARY PREVENTION OF ISCHEMIC STROKE - DESIGN, SERVICE AVAILABILITY, AND COMMON PRACTICES
US NATIONAL SURVEY OF PHYSICIAN PRACTICES FOR THE SECONDARY AND TERTIARY PREVENTION OF ISCHEMIC STROKE - DESIGN, SERVICE AVAILABILITY, AND COMMON PRACTICES
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DOI：
10.1161/01.str.26.9.1607
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发表时间：
1995-09-01
期刊：
影响因子：
8.3
通讯作者：
SAMSA, GP
中科院分区：
文献类型：
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作者：
GOLDSTEIN, LB;BONITO, AJ;SAMSA, GP
背景和目的中风在很大程度上是一种可预防的疾病。然而，关于执业医师使用中风预防诊断和治疗方式的数据很少。这些数据对于资源的合理配置和教育工作的针对性至关重要。这项全国性调查的目的是收集有关医生中风预防实践模式以及他们对二级和三级中风预防策略的态度和信念的信息。方法我们对从美国医学会医师主档案中抽取的 2000 名医生分层随机样本进行了全国性中风预防实践调查。该调查的重点是中风风险较高的患者的服务可用性以及诊断和预防策略的使用。结果，67% (n=1006) 的合格医生完成了调查。至少 90% 的医生认为可以轻松进行的诊断研究包括颈动脉超声检查、经胸超声心动图、动态心电图监测以及脑部 CT 和 MRI 扫描。 68% 的受访者认为磁共振血管造影很容易获得，74% 的受访者认为经食管超声心动图很容易获得。 12% 的医生报告称无法进行脑动脉造影，10% 的医生报告称颈动脉内膜切除术不易实现。多重逻辑回归分析显示，服务的可用性因医生专业（非内科初级保健、内科、神经病学、外科）、实践环境（非大都市与小都市或大都市地区）以及颈动脉内膜切除术、国家地区（南部、中部、东北和西部）而异。据报告，在中部、东北部和西部地区执业的医生容易获得颈动脉内膜切除术的几率比在南方地区执业的医生高出约 2.5 至 3.5 倍，与执业环境和专业无关。关于中风预防实践，61% 的医生报告开出 325 毫克阿司匹林来预防中风，而 33% 的医生建议剂量低于 325 毫克，4% 的医生建议使用 650 毫克或更多剂量。 71% 使用华法林的医生报告称，他们使用国际标准化比率来监测抗凝效果。 78% 的受访者报告每月至少监测一次抗凝患者。不到 20% 的医生表示了解自己进行手术或转诊患者进行手术的医院的围手术期颈动脉内膜切除术并发症发生率。 结论 虽然大多数医生都可以随时获得用于二级和三级卒中预防的所有常规和最专业的服务，但可用性存在差异。使用国际标准化比率来监测华法林治疗尚未普及。医生普遍缺乏对颈动脉内膜切除术并发症发生率的了解。根据其原因，这些问题可以通过有针对性的医生教育工作和服务提供方式的系统性改变来解决。
Background and Purpose Stroke is largely a preventable disease. However, there are little data available concerning the use of stroke prevention diagnostic and treatment modalities by practicing physicians. These data are critical for the rational allocation of resources and targeting of educational efforts. The purposes of this national survey were to gather information about physicians' stroke prevention practice patterns and their attitudes and beliefs regarding secondary and tertiary stroke prevention strategies.Methods We conducted a national survey of stroke prevention practices among a stratified random sample of 2000 physicians drawn from the American Medical Association's Physician Masterfile. The survey focused on the availability of services and the use of diagnostic and preventive strategies for patients at elevated risk of stroke.Besults Sixty-seven percent (n=1006) of eligible physicians completed the survey. Diagnostic studies considered readily available by at least 90% of physicians included carotid ultrasonography, transthoracic echocardiography, Holter monitoring, and brain CT and MRI scans. MR angiography was perceived as being readily available by 68% and transesophageal echocardiography by 74% of respondents. Twelve percent of physicians reported cerebral arteriography and 10% reported carotid endarterectomy as not being readily available. Multiple logistic regression analyses showed that the availability of services varied with physician specialty (noninternist primary care, internal medicine, neurology, surgery), practice setting (nonmetropolitan versus small metropolitan or large metropolitan areas), and for carotid endarterectomy, region of the country (South, Central, Northeast, and West). The odds of carotid endarterectomy being reported as readily available were approximately 2.5 to 3.5 times greater for physicians practicing in the central, northeastern, and western regions compared with those practicing in the South, independent of practice setting and specialty. With regard to stroke prevention practices, 61% of physicians reported prescribing 325 mg of aspirin for stroke prevention, while 33% recommend less than 325 mg and 4% use doses of 650 mg or more. Seventy-one percent of physicians using warfarin reported monitoring anticoagulation with international normalized ratios. and 78% reported monitoring anticoagulated patients at least once a month. Fewer than 20% of physicians reported knowing the perioperative carotid endarterectomy complication rates at the hospital where they perform the operation themselves or refer patients to have the procedure done.Conclusions Although all routine and most specialized services for secondary and tertiary stroke prevention are readily available to most physicians, variation in availability exists. The use of international normalized ratios for monitoring warfarin therapy has not yet become universal. Physician knowledge of carotid endarterectomy complication rates is generally lacking. Depending on their causes, these problems may be addressed through targeted physician education efforts and systematic changes in the way in which services are provided.