Aile hekimlerinin demir eksikliği ile ilgili tanı ve tedavi yaklaşımlarının değerlendirilmesi
Evaluation of diagnosis and treatment approaches related to iron deficiency of family physicians
Yazar: KAMİL KONUR
Danışman: PROF. DR. ELİF AKDOĞAN
Recep Tayyip Erdoğan Üniversitesi / Tıp Fakültesi / İç Hastalıkları Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2021
Konu: İç Hastalıkları = Internal diseases
Dizin: Aile hekimliği = Family practice ; Anemi-demir eksikliği = Anemia-iron deficiency ; Doktorlar = Physicians ; Doktorlar-aile = Physicians-family ; Tedavi = Treatment ; Teşhis = Diagnosis

Özet:
Bulgular: Katılımcıların 73'ü (%90,1) pratisyen hekim iken, 8'i (%8,9) aile hekimi uzmanıdır. Çalışmaya katılmış olanların 17'sini kadınlar (%20,9), 64'ünü (%79,1) erkek hekimler oluşturmuştur. Katılımcıların yaş dağılımına bakıldığında 22 kişi (%27,2) 25-35 yaş grubunda, 38 kişi (%46,9) 36-45 yaş grubunda, 21 kişi (%25,9) ise 45 yaş üzeri grupta yer almıştır. Hekimlerin %91,4'ü (=74) hastaların tanı ve tedavisini tıp fakültesinde öğrendiği veya uzmanlık süresinde edindiği bilgilere göre yaptığını görülmektedir. Mezuniyet veya uzmanlık sonrası demir eksikliği ile ilgili bir seminer veya eğitim toplantısına katıldığını bildiren hekim oranı %58'dir (=47). Demir eksikliği tedavisi ile ilgili bir rehber okuduğunu belirten hekim oranı %71,6 (=58) iken bu konuda eğitim almak isteyen hekim oranı %87,6 (=71) olmuştur. Erkeklerde ve kadınlarda anemi tanımı için Hb eşik değerini doğru bilen hekim oranı sırasıyla %46,9 (=38) ve %55,6 (=45) olmuştur. Akut enfeksiyon tablosu olmayan bir hastada DEA tanısı koyabilmek için ferritin değerini doğru bilen hekim oranı %70,4 (=57) bulunmuştur. DEA düşünülen bir hastada hekimlerin hangi semptomları sorguladıkları sorulduğunda en çok sorgulanan semptomun %90,1 oranında menoraji olduğu görülmektedir. Bunun haricinde çoktan aza doğru %87,7 oranında melena, %84 oranında pika ve saç dökülmesi, %72,8 oranında kilo kaybı ve hematokezya, %55,6 oranında mide ağrısı ve reflü semptoları, %54,3 oranında parazit öyküsü, %40,7 oranında dispne, %35,8 oranında huzursuz bacak semptomları ve %27,2 oranında göğüs ağrısı gelmektedir. DEA teşhisi konulduktan sonra gastrointestinal sistem taraması erkeklerde, hekimlerin %39,5'i (=32) tarafından tüm erkeklere önerilirken kadınlarda, hekimlerin %87,7'si (=71) tarafından postmenopozal dönemde olanlar için önerilmiştir. Vaka sorularında asemptomatik DEA hastalarına sırasıyla %66,7 (=54) ve %24,7 (=20) oranında +2 değerlikli demir preparatı önerilmiştir. DEA'lı hastada yüksek trombosit değerlerini anemiye sekonder olarak düşünen hekim oranı %31,8 (=29) olmuştur. DEA tedavi süresinin Hb düzeyi normale geldikten sonra 3-6 ay kadar devam etmesini öneren hekim oranı %93,8 (=76) bulunmuştur. Oral demir tedavisi ile Hb değerinde yükselme olmazsa katılımcılar en sık %81,5 (=66) oranında kanama, %59,3 (=48) oranında Çölyak Hastalığı, 40,7 (=33) oranında Helicobacter Pylori ve %44,4 (=36) oranında ise bunların hepsini düşünmek gerektiğini belirtmişlerdir. İleri yaş, KAH'ı olan, semptomatik anemili hastaya hekimler %53,1 (=43) oranında eritrosit süspansiyonu sonrası oral demir tedavisini önermişlerdir. Sonuç: Çalışmamıza göre aile hekimlerinin DEA yönetimi konusunda bilgi düzeylerinin yetersiz olduğu, tanı ve tedavi süreçlerinde eksikliklerin olduğu görüldü. Aile sağlığı merkezlerinde interaktif, uygulamalı hizmet içi eğitim programları
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düzenlenmelidir. Ayrıca DEA tanı ve tedavisi yönetimi açısından hem yerel hem de ulusal kılavuzların oluşturulup pratik anlamda kullanımı sağlanmalıdır. Hem eğitim hem de hastaların yönetimini daha güçlü kılmak adına aile hekimlerinin iç hastalıkları klinikleri ile iletişimini ve irtibatını artıracak programlar ve modeller planlanmalıdır.
Anahtar Kelimeler: Demir eksikliği anemisi, anemi, aile hekimi

Abstract:
Introduction and purpose: Anemia is defined by the World Health Organization (WHO) if the hemoglobin (Hb) value is below 13 g/dL in men and 12 g/dL in women. In pregnant women, anemia is accepted as 11 g/dL and below (1). The clinical manifestations occurring in patients with iron deficiency anemia (IDA); It is associated with age, severity of anemia, comorbid diseases, and the duration of anemia. As a result of tissue hypoxia, we may encounter complaints such as weakness, fatigue, dizziness, headache and palpitations (119). With or without symptoms, IDA or iron deficiency without anemia should be treated. Because as long as iron stores are not filled, anemia can deepen and cause organ ischemia (120). It was observed that there were serious differences between the diagnosis and treatment modalities among physicians in the management of anemia. In this sense, it was stated that there is a need for evidence-based local/national guidelines (105, 106). With this study, we aimed to evaluate the management of iron deficiency anemia of family physicians according to guidelines, since wide differences were seen in the diagnosis and treatment approaches of patients referred from family medicine to the Recep Tayyip Erdogan University Training and Research Hospital Hematology Department.
Material and Method: Our study was conducted between 15 December 2020 and 15 January 2021. The population of our study consists of a total of 101 physicians, including general practitioner family phsicians and specialist family physicians, who are actively working in family health centers in Rize. The study included 81 physicians who are participated in voluntarily. Our research is a cross-sectional descriptive study. As a data collection tool, a 20-question questionnaire including sociodemographic characteristics, prepared by scanning the literature, was presented to the participants. Pearson Chi-Square Test and Fisher's Exact Test were used to evaluate categorical variables. Statistical significance level was accepted as p <0.05.
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Results: While 73 (90.1%) of the participants are general practitioner family phsicians, 8 (8.9%) are specialist family physicians. Of those who participated in the study, 17 were female (20.9%) and 64 (79.1%) were male physicians. The age distribution of the participants, 22 (27.2%) were in the 25-35 age group, 38 (46.9%) in the 36-45 age group, and 21 (25.9%) in the 45-year-old group. It is seen that 91.4% of the physicians (= 74) made the diagnosis and treatment of the patients according to the information they learned at the medical school or obtained during their specialty period. The rate of physicians who stated that they attended a seminar or training meeting on iron deficiency after graduation or specialty is 58% (= 47). While the rate of physicians who stated that they read a guide on iron deficiency treatment was 71.6% (= 58), the rate of physicians who wanted to receive training on this subject was 87.6% (= 71). The rate of physicians who knew the Hb threshold value correctly for the definition of anemia in men and women were 46.9% (= 38) and 55.6% (= 45), respectively. The rate of physicians who knew the value of ferritin correctly in order to make a diagnosis of IDA in a patient without acute infection was found to be 70.4% (= 57). When asked which symptoms the physicians questioned in a patient with suspected IDA, it was seen that the most frequently questioned symptom was menorrhagia at a rate of 90.1%. Except this 87.7% melena, 84% pica and hair loss, 72.8% weight loss and hematochezia, stomach pain and reflux symptoms at 55.6%, 54.3%. parasite history, 40.7% dyspnea, 35.8% restless leg symptoms and 27.2% chest pain. After diagnosis of IDA, screening of the gastrointestinal system was recommended for men by 39.5% (= 32) of physicians, while it was recommended for women by 87.7% (= 71) of physicians for those in the postmenopausal period. In case questions, asymptomatic IDA patients were recommended an iron preparation of +2 in 66.7% (= 54) and 24.7% (= 20), respectively. The rate of physicians who consider high platelet values secondary to anemia in patients with IDA was 31.8% (= 29). The rate of physicians who recommended that the duration of IDA treatment be continued for 3-6 months after the Hb level is normalized was 93.8% (= 76). If there was no increase in the Hb value with oral iron treatment, the most frequent participants were bleeding 81.5% (= 66), Celiac Disease 59.3% (= 48), Helicobacter Pylori 40.7 (= 33) and 44.4% ( = 36) stated that it is necessary to consider all of them. Physicians recommended 53.1% (= 43) oral iron treatment after erythrocyte suspension to patients with advanced age, CAD and symptomatic anemia.
Conclusion: According to our study, it was observed that family physicians did not have sufficient knowledge about the management of IDA and there were deficiencies in the diagnosis and treatment processes. Interactive, applied in-service training programs should be organized in family health centers. In addition, both local and national guidelines should be created and used in practical terms in terms of IDA diagnosis and treatment management. Programs and models that will increase the communication and contact of family physicians with internal medicine clinics should be planned in order to make both education and management of patients stronger.
Keywords: Iron deficiency anemia, anemia, family physician