Community general practitioner trainers’ knowledge and training needs of asymptomatic carotid stenosis management and prevention: a cross-sectional study

doi:10.21203/rs.3.rs-2070754/v1

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Community general practitioner trainers’ knowledge and training needs of asymptomatic carotid stenosis management and prevention: a cross-sectional study

https://doi.org/10.21203/rs.3.rs-2070754/v1

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Background

To investigate the general practitioner (GP) trainers’ knowledge level of asymptomatic carotid stenosis (ACS) management and the impact factors, and their potential training needs in community training bases of General Practitioners' Standardized Training (GPST).

Methods

A regional cross-sectional study was conducted. All the community GP trainers in Liaoning GPST institutes were included. We use a self-designed instrument to collect participants’ general information, knowledge of ACS management and prevention, and training needs.

Results

Between Mar 2022 and April 2022, 167 participants were invited in Community Base of Liaoning GPST, 134 GP trainers’ answers were reliable and were included in the final analysis. The mean score of GP trainers’ knowledge of ACS prevention and management was 13.04 with an accuracy rate of 0.38. Gender (OR: 2.93) and working experience as a GP (OR: 2.84) were the significant impact factors(P < 0.05). The majority of GP trainers would like to be trained to improve their knowledge while only nearly 20% prefer high-frequency training.

Conclusions

In Liaoning province, community GP trainers’ knowledge of ACS management and prevention was at a low level. Gender and years of working experience as a GP were major impact factors on the GP trainers’ knowledge.

general practitioner

asymptomatic carotid stenosis

knowledge

training

community

Asymptomatic Carotid Stenosis (ACS) is the common form of the early stage of cerebrovascular diseases. Nearly 15% of first-ever ischemic stroke has an association with > 50% asymptomatic carotid stenosis(1, 2). The prevalence of ACS can increase with age. The prevalence of ACS in China is unclear, while a European study showed that the prevalence of ACS varied from 0.3% among adults ages under 50 years to 5.7% among adults older than 80 years(3). The severity degree of carotid stenosis is also associated with stroke events(4). To reduce the risk of stroke events caused by ACS, carotid endarterectomy, carotid stenting and best medical treatment (BMT) were applied as useful interventions(5). BMT included medical therapy and lifestyle adjustment. The evidence showed that BMT intervention can effectively decrease the risk of stroke events among adults with mild to moderate ACS(6).

In China, general practitioners (GPs) are mainly responsible for primary care, especially chronic disease management. Prevention of stroke events through BMT among patients with ACS is also one of the important works for GPs, which require GPs to have up-to-date knowledge and practice level with regard to ACS(7). There are two training models for GPs in China: job-transfer training and “5 + 3” training. Under the “5 + 3” training model, GPs are required to receive 3 years of standardized training in hospitals and community after 5 years of medical education in medical school(8). During the 3 years of standardized training, GPs are required to spend 7 months in the community training bases of general practitioners standardized training institute to update their knowledge and practice level. During these 7 months, the qualified GP trainers acted as the teachers of GPs(9, 10). Obviously, community GP trainers’ knowledge level in terms of ACS will impact the GPs’ knowledge and skills to manage ACS patients.

Liaoning province is the north center of the GP standard training of stroke and undertakes the responsibility to explore the effective training models of GPs in north China. However, the first important step is to figure out GP trainers’ knowledge level and training needs of ACS. Although all the qualified GP trainers in Liaoning Province need to participate and pass the knowledge and practice test regularly, the specific knowledge level of ACS prevention and management of GP trainers is still unknown.

In this cross-sectional study, we aim to investigate the community GP trainers’ knowledge of ACS prevention and management, and their potential training needs.

Study Design and participants

This cross-sectional study was conducted from Mar 2022 to April 2022 in 35 general practitioners' standardized training (GPST) institutes in Liaoning province. All the GPs who met the following inclusion criteria were invited and were regarded as GP trainers: 1) recognized the teacher qualification certificate of general medicine; 2) held the title of attending physician or above; 3) medical education level is a college graduate degree or above; 4) At least 3 years working experience as a GP or family practitioner (FP) in community. The exclusion criteria were as follows: 1) refuse to participate in this study; 2) have psychological disorder or dementia. We obtained written informed consent from all study participants.

Development of self-designed instrument.

We conducted a questionnaire to investigate GP trainers’ knowledge of asymptomatic carotid stenosis management and potential training needs. The questionnaire consists of three sections:

1) Section A was used to collect the general information of the participants including sex, age, region, medical education level, major, title, employment institution, working experience as clinical physicians and general practitioners and participation in family physician contract service.

2) Section B was designed to acquire knowledge of asymptomatic carotid stenoses. In the first stage, we reviewed the relative guidance and references to summarize the main knowledge fields of asymptomatic carotid stenosis management (11–16). After internal discussion and external consultation, the final questionnaire consists of six fields: definition and epidemiology (2 items), screening and diagnosis (4 items), management objectives (4 items), intervention and management (14 items), follow-up (6 items) and referral (4 items).

3) Section C was conducted to explore the training needs of general practitioners for ACS including training content, training method, and training frequency. We invited seven GPs to test the content validity of this questionnaire. Cronbach's Alpha was 0.81 and the content validity indice was 0.92.

Based on the above criteria, in total, 167 GP trainers were selected and invited to participate in this study. Among them, 143 GP trainers completed this survey, and the overall response rate was 85.62%. After checking the results, we excluded 9 individuals due to the missing values and unreliable answers. Finally, 134 GP trainers were included in the analysis (Fig. 1).

Data Collection

We used the Wechat Survey Platform to distribute the questionnaire to all the participants. Before the survey, we conducted online training to help the participants correctly understand all the items. All the participants were told to complete the survey independently without discuss with others. We gave every participant unique access based on their Wechat account to prevent duplicate responses.

Outcome statistics and evaluation

The primary outcome was the knowledge score, which was calculated based on the correct answers. Each correct answer scored one point and the wrong answer scored zero point. The total score ranges from 0 to 34, Higher scores indicate better performance in the knowledge of ACS management. To investigate the factors of knowledge level, we use the knowledge level as the outcome which is calculated based on the knowledge score. If the participant’s knowledge score was higher than the mean score, the knowledge level was labelled as “High”. If the knowledge score was lower than the mean score, the knowledge level was labelled as “low”. The secondary outcome was participants’ training needs.

Statistical analysis

Categorical variables were presented as numbers (n) with percentages (%). Numerical variables were presented as the mean with standard deviation (SD) or median with interquartile range (IQR). The Chi-square test and Fisher’s exact test were used to compare the differences in categorical variables. We did Univariate and multivariable logistic regression analyses to investigate impact factors for GP’s knowledge level. Variables with a p-value < 0.05 in the univariate logistic regression analysis were entered into multivariate logistic regression analysis. A two-tailed p-value of < 0.05 was considered statistically significant. Data analysis was conducted using SPSS 23.0 (Statistical Package Program for )Social Sciences 23.0, SPSS Inc., Chicago, IL, USA).

Baseline characteristics of included community GP trainers

As shown in Table 1, among included GP trainers, more women (72.39%) participated in our study than men (27.61%). The majority of them were older than 45 years old (61.94%). Meanwhile, most of them graduated in the specialty of clinical medicine (79.10%) and with a bachelor’s degree (80.60%). And, over half of them were senior physicians (55.22%). Though 63.43% of GP trainers owned over 20 years of working experience as clinical physicians, only 10.45% of them had 20 years of working experience as general practitioners. In terms of region, over half of the GP trainers came from Shenyang central region (52.98%), followed by the east and south region (36.57%), and the west and north region (10.45%).

ACS prevention and management knowledge among community GP trainers

• Score analysis of six fields

The mean score of ACS prevention and management knowledge was 13.04 with an accuracy rate of 0.38 (Table 2). The accuracy rates in the definition and epidemiology field, and the screening and diagnosis field was higher than 0.5 (0.80 and 0.59, respectively). While the accuracy rates in the field of management objectives, intervention and management, follow-up, and referral were all lower than 0.5 (0.26, 0.30, 0.31, 0.43 respectively).

• Analysis of the accuracy rate of answering the questionnaire

Figure 2 reflects the answers to all 34 questions in the six fields by GP trainers. The accuracy rate for ‘Frequency of carotid ultrasound (Q25)’ was only 13.43%, and for ‘Surgical indications for ACS’ were only 11.19%. According to the management of hypertension and dyslipidemia(Q9, Q16, Q17, Q33, Q11), the correct rates were high (> 50%). And for ‘Goals for Lifestyle intervention (Q7), the accuracy rate was only 0.75%, and 88.10% of them chose the wrong option ‘decrease smoking intensity. The accuracy rate for ‘Smoking cessation (Q24)’ was 24.63%, and 49.30% of them chose wrong option ‘e-cigarette replacement therapy. For ‘HbAc1 control targets for elderly diabetes mellitus (Q8)’ and ‘Principles of geriatric diabetes treatment (Q21)’, the correct rates were also low, which was 10.45% and 1.49%, respectively.

Univariate Analysis of ACS prevention and management knowledge among community GP trainers

In the univariate analysis, gender, title and working experience as a general practitioner were significantly associated with the knowledge level of GP trainers (P < 0.05). Women, with senior titles and 10 + years of working experience as GP, can perform better in the ACS prevention and management knowledge test. Other factors had no association with the knowledge level (Table 3).

Multivariate Analysis of ACS prevention and management knowledge among community GP trainers

In the multivariate analysis summarized in Table 4, gender, title and working experience as a GP were included as the factors in the logistic regression model. The multivariate logistic regression result showed that gender and working experience as a GP were the significant impact factors. Female trainers (OR: 2.93, 95%CI 1.31–6.16) and trainers with 10 + working years as GP (OR: 2.84, 95%CI 1.31–6.16) had a higher knowledge level of ACS prevention and management.

Community GP trainers’ training demand for ACS prevention and management

To better understand the training demand of community GP trainers, we also collected the GP trainers’ opinions on the training content, frequency and methods (Table 5). The majority of GP trainers (89.55%) would like to accept professional training in ACS prevention and management. In terms of the training content, health education was the most needed (91.04%), followed by drug therapy (85.82%), diagnosis and evaluation (85.07%), follow-up management (76.12%), complication management (73.13%) and referrals (67.91%). For the training frequency, only 17.16% of them prefer the high frequency (weekly: 8.95%, biweekly: 8.21%, monthly: 32.84% and quarterly: 50.00%). Regarding the training method, expert lectures (91.79%) and case-based discussion (65.67%) were more favour than other training formats.

To the best of our knowledge, our study is the first survey of community GP trainers’ knowledge and training needs towards ACS prevention and management at the province level. First, our result showed that Liaoning province’s community GP trainers’ knowledge level (measured by accuracy rate: 0.38) of ACS prevention and management, was low. Second, gender and the years of working experience as a GP were the significant impact factor on knowledge level. That means female GP trainers with 10 + years of working experience as GP were more likely to have a better knowledge level towards ACS prevention and management. Last, the majority of GP trainers would like to be trained to improve their knowledge, while only nearly 20% prefer of them prefer high-frequency training.

Although the survey of Chinese community GP trainers’ knowledge is limited, some studies have ever reported the GP’s knowledge level of chronic disease. Yang and her colleagues had a survey on the GP’s knowledge about mastery of type 2 diabetes prevention, and the accuracy rate was 0.54(17). Another study to investigate the GP’s knowledge about hypertension in Shanghai showed the average accuracy rate was 0.49(8). Compared with mastery of type 2 diabetes and hypertension, GP trainers had poor knowledge of ACS prevention and management (accuracy rate: 0.38). Considering the participants in our studies were all GP trainers (generally their knowledge level should be higher than the average level of GPs), such an obvious difference indicates that ACS-related knowledge may be ignored by community GPs and GP trainers in China.

According to the guidelines, from the perspectives of GPs, regular surveillance and stroke-related risk factors management should be the primary treatment objective of ACS patients(11). Our result showed that only 13.43% of GP trainers were clear about the correct ultrasound surveillance frequency. Most of the GP trainers selected the frequency of three months or six months, which may result in higher expenditure on that. In addition, only 11.19% of GP trainers can correctly recognize the patients that need to be referred to general hospitals. This low awareness rate is consistent with the result of a prior national survey(18). Hypertension, dyslipidemia, diabetes mellitus, and smoking are the four major risk factors for stroke in ACS patients(19). Our study found that GP trainers have a good performance in hypertension and dyslipidemia management, while their knowledge of diabetes mellitus and smoking control is poor. ACS patients should be informed that smoking is an independent risk factor for stroke, and be advised to quit this habit. However, 88.10% of GP trainers selected “decrease smoking intensity” but not “quit smoking”. In terms of diabetes management, the accuracy rates of “treatment principle of type 2 diabetes mellitus in elderly patients” and “target HbA1c (glycated haemoglobin)” were 1.50% and 10.40%, respectively. A cross-sectional study in Shanghai aimed to evaluate the GPs’ knowledge of type 2 diabetes mellitus and also showed that the above two questions were the weak points(17). These all indicate we should attach importance to regular surveillance, smoking management and diabetes mellitus management in the future training for community GPs and GP trainers.

Our study also found that gender and years of working experience as a GP were the significant impact factor on the knowledge level of ACS management. Our study showed female trainers’ performance was significantly better than male trainers. Female GPs seem always to perform better than male GPs in practice and examination. This phenomenon was also found in studies to evaluate GPs’ knowledge of chronic obstructive pulmonary disease and sudden cardiac death prevention in China(19, 20). The authors explained that women were more positive in learning and more carefully in answering the questions. Also, a national study in Norway found the referral rate of female GPs to secondary care was 25% higher than that of male GPs(21). They considered this result indicates a female tendency to attempt to reduce uncertainty. The results of another study indicated that female GPs are more interested in career training, as well as being more willing to invest time in in-depth learning(22). Thus, female GPs have better fundamental knowledge and skills than male GPs. All of them indicate that male community GP trainers and GPs should be attached more importance in future training.

In addition, we found community GP trainers’ knowledge level is associated with their working experience as GPs, as well as their titles and education levels. This relationship between working experience and knowledge was also reported in previous studies(23). The value of practice experience to grasp knowledge has been discussed a lot before. Although some researchers did not agree to practice experience that is more important than theoretical learning(24, 25), the majority of the studies have shown its irreplaceable value in grasping knowledge. Benner et al. believe that theoretical and practical knowledge support each other(26). Katajavouri et al. concluded that practice can do help to recognise the need for certain theoretical components and demonstrate how these theoretical components can be applied practically(27). In China, compared with specialist physicians, the majority of on-jobing general practitioners’ training programs and educational content are diverse and unnormalized, therefore their working experience in the real world may help to improve their understanding of ACS management.

Another interesting finding of our study is that the majority of GP trainers would like to be trained to improve their knowledge, while only nearly 20% prefer high-frequency training. In our study, the average age of participants is 46, which may be the main reason for the interesting result.

Our study findings have important implications for GPs' education and training. With the rapid ageing of China, GPs will take more responsibility to secure the health of residents. Taking “ACS management and prevention” as an example, GP trainers’ knowledge is urgent to be improved. Further training should be focused on management objectives, intervention and management, follow-up, and referral. Male and young GP trainers deserve special attention. Our study calls for national or regional policies and programmes for community GP trainers and GPs, especially in the field of ACS management and prevention.

Our study has several limitations. First, the community GP trainers included were all from Liaoning province which cannot represent the average status of China due to the diversity of regions. Furthermore, the total response rate was 85.6%. The main reason to reject this survey is that they are too busy dealing with the covid-19 pandemic and all of them are senior GP trainers. This may lead to the average knowledge score being lower than the truth. Last, the knowledge data were only collected by the self-designed instrument without any observation in the practice, which may not present the knowledge level of GP trainers.

In conclusion, in Liaoning province, GP trainers’ knowledge of ACS management and prevention is at a low level in community training bases. Gender and years of working experience as a GP are major impact factors on the GP trainers’ knowledge. The training and education program in terms of ACS management and prevention for Community GP trainers should be designed to improve the GPs’ knowledge and capabilities in China.

Full name	Abbreviations
General practitioner	GP
General practitioners	GPs
Asymptomatic carotid stenosis	ACS
General Practitioners' Standardized Training	GPST
Best medical treatment	BMT

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of the First Affiliated Hospital of China Medical University (AF-SOP-07-1.1-01). Written informed consent was obtained from all the participants.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests

Funding

This study was supported by the Public Livelihood Fund of Liaoning Provincial Science and Technology Department (2021JH2/10300014).

Author Contributions

All authors were involved in the study concept and design. MCC, KY and XYC initially collected and analysed the data and discussed the results with SW. The first draft was written by MCC and XTG. All authors commented on previous versions of the manuscript. All authors read and approved the final version of the manuscript.

Acknowledgements

We would like to thank all the participants involved in the study. We greatly appreciate the support provided by the Health Commission of Liaoning Province in the investigation process.

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Table 1. Characteristics of the Participants.

Characteristics	Total n (%)
Gender
Male	37 (27.61%)
Female	97 (72.39%)
Age(years)
＜45	51 (38.06%)
≥45	83 (61.94%)
Specialty
Clinical Medicine	106 (79.10%)
Others	28 (20.90%)
Medical education level
Associate’s degree or below	21 (15.67%)
Bachelor’s degree	108 (80.60%)
Master’s degree or above	5 (3.73%)
Title
Attending Physician	60 (44.78%)
Senior Physician	74 (55.22%)
Working experience as a clinical physician (years)
＜10	16 (11.94%)
10-20	33 (24.63%)
≥20	85 (63.43%)
Working experience as a general practitioner (years)
＜10	79 (58.95%)
10-20	41 (30.60%)
≥20	14 (10.45%)
Region
Shenyang central region	71 (52.98%)
East and south region	49 (36.57%)
West and north region	14 (10.45%)

Data were presented as n (%).

Table 2. ACS prevention and management knowledge among community GP trainers.

Field	Full Score	Score (Mean ± SD)	Accuracy Rate (Mean ± SD)
Definition and epidemiology	2	1.60 ± 0.49	0.80 ± 0.25
Screening and diagnosis	4	2.36 ± 0.10	0.59 ± 0.25
Management objectives	4	1.04 ± 0.76	0.26 ± 0.19
Intervention and management	14	4.28 ± 2.00	0.30 ± 0.14
Follow-up	6	1.90 ± 1.16	0.31 ± 0.19
Referral	4	1.75 ± 0.66	0.43 ± 0.16
Total	34	13.04 ± 3.76	0.38 ± 0.10

¹ Data were presented as Mean ± SD.

Table 3. Univariate Analysis of ACS prevention and management knowledge among community GP trainers.

Characteristics	Low level n（%）	High level n（%）	P
Gender
Male	29（78.38%）	8（21.62%）	0.027^†
Female	56（57.73%）	41（42.27%）
Age(years)
＜45	34（66.67%）	17（33.33%）	0.542^†
≥45	51（61.45%）	32（38.55%）
Specialty
Clinical Medicine	65（61.32%）	41（38.68%）	0.323^†
Others	20（71.43%）	8（28.57%）
Medical education level
Associate’s degree or below	13 (61.90%)	8 (38.10%)
Bachelor’s degree	71 (65.74%)	37 (34.26%)	0.114^‡
Master’s degree or above	1 (20.00%)	4 (80.00%)
Title
Attending Physician	44（73.33%）	16（26.67%）	0.032^†
Senior Physician	41（55.41%）	33（44.59%）
Working experience as a clinical physician (years)
<10	12（75.00%）	4（25.00%）	0.306^†
≥10	73（61.86%）	45（38.14%）
Working experience as a general practitioner (years)
<10	59（74.68%）	20（25.32%）	0.001^†
≥10	26（47.27%）	29（52.73%）
Region
Shenyang central region	50（70.42%）	21（29.58%）	0.077^†
East and south region	25（51.02%）	24（48.98%）
West and north region	10（71.43%）	4（28.57%）
Providing family doctor signing service
Yes	70（61.95%）	43（38.05%）	0.407^†
No	15（71.43%）	6（28.57%）
Received training of ACS management
Yes	25（45.95%）	12（54.05%）	0.539^†
No	60（58.44%）	37（67.53%）

Data were presented as n (%) as appropriate.

^†Chi-squared test, ^‡Fisher’s exact test.

Table 4. Multivariate Analysis of ACS prevention and management knowledge among community GP trainers.

Factor	OR	95% CI	P
Gender
Female Male	2.93	1.17 - 7.36	0.022
Working experience as a general practitioner(years)
>10 ≤10	2.84	1.31 - 6.16	0.008
Title
Senior Physician Attending Physician	2.00	0.91 - 4.42	0.086

Table 5. Community GP trainers’ training demand for ACS prevention and management.

Questions and response	n (%)
Would you like to attend training courses on ACS prevention and management regularly?
Yes	120 (89.55%)
No	14 (10.45%)
What kinds of training content would you like to be included in the training? (multi-choice)
Health education	122 (91.04%)
drug therapy	115 (85.82%)
diagnosis and evaluation	114 (85.07%)
follow-up management	102 (76.12%)
complication management	98 (73.13%)
referrals	91 (67.91%)
What is the most appropriate frequency of training?
Weekly	12 (8.95%)
Bi-weekly	11 (8.21%)
Monthly	44 (32.84%)
Quarterly	67 (50.00%)
What kinds of training methods do you prefer to be used in the training?
Expert lectures	123 (91.79%)
On-site guidance	57 (42.54%)
Case-based discussion	88 (65.67%)
Community workshop	56 (41.79%)
Others(online)	2 (1.49%)

Data were presented as n (%).

No competing interests reported.

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Community general practitioner trainers’ knowledge and training needs of asymptomatic carotid stenosis management and prevention: a cross-sectional study

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