三级甲等医院指导下慢性心力衰竭患者的社区管理研究
삼급갑등의원지도하만성심력쇠갈환자적사구관리연구
Community-based management for chronic heart failure patients under the professional guidance of upper first-class hospital staff
  • 万方数据
    中华心血管病杂志 중화심혈관병잡지
    Chinese Journal of Cardiology
    2012年 11期 939-944 ,共6页

    李锦%王引利%余秀琼%吴镜%唐超%巫文丽%戴玫%蒋晖%唐炯%蔡琳

    리금%왕인리%여수경%오경%당초%무문려%대매%장휘%당형%채림

    心力衰竭,充血性%疾病管理%社区医学 心力衰竭,充血性%疾病管理%社區醫學
    심력쇠갈,충혈성%질병관리%사구의학
    Heart failure,congestive%Disease management%Community medicine
    目的 建立一个三级甲等医院指导下慢性心力衰竭患者的社区管理模式.方法 以成都市青羊区苏坡社区和周边新都区城东社区两个区域作为研究基地,入选200例35～85岁NYHA心功能分级Ⅱ～Ⅳ级的慢性心力衰竭患者.以街道和小区为基本单元,采用整群随机分组方法,将其分为干预组(共11个自然居民小区,100例患者)和对照组(共11个自然居民小区,100例患者).三级甲等医院对青羊区苏坡社区和新都区城东社区医院医生(22名)进行标准化心力衰竭诊治培训,医生参与干预组的随访管理;同期对干预组患者进行分次自我管理教育.对照组不进行任何干预.主要随访指标包括社区医生对心力衰竭的知晓率、诊断阳性率、对标准化治疗的接受程度;患者心力衰竭的知晓率、服药率、标准化药物使用率、自我管理能力、生活质量、心血管事件、住院时间和医疗花费.结果 标准化心力衰竭诊治培训后,社区医生心力衰竭的知晓率[培训前后心力衰竭药物治疗和生活指导分别为13.6％(3/22)和100％(22/22),心力衰竭病因相关防治知识分别为22.7％(5/22)和100％ (22/22)]、诊断阳性率[培训前后分别为51.8％ (100/193)和87.0％(168/193)]、标准化治疗接受程度[培训前后β受体阻滞剂分别为22.7％ (5/22)和77.3％ (17/22),血管紧张素转换酶抑制剂分别为27.2％ (6/22)和63.6％ (14/22)]均较培训前增高(P均＜0.05).干预组有效患者96例,对照组有效患者97例.随访时间为(18.5±0.5)个月.干预组患者的疾病知晓率[100％(96/96)比71.1％ (69/97)]、服药率[78.1％ (75/96)比13.4％ (13/97)]、标准化药物使用率[β受体阻滞剂75.0％(72/96)比8.2％(8/97),血管紧张素转换酶抑制剂60.4％(58/96)比10.3％(10/97)]、自我日常生活管理率[限盐、控制饮食88.5％ (85/96)比29.9％ (23/97)、监测血压83.3％(80/96)比56.7％ (55/97)、监测体质量78.1％(75/96)比13.4％(13/97)]均高于对照组(P均＜0.05).在61例心功能Ⅲ～Ⅳ级患者中,干预组的生活质量量表总分[(43.7±9.2)分比(49.5±11.3)分]、心血管事件发生率[63.3％ (19/30)比90.3％ (28/31)]、住院时间[(8.2 ±3.2)d比(13.9±10.9)d]、住院总费用[(2873.3±401.6)元比(4525.8±6417.8)元]均低于对照组(P均＜0.05).结论 三级甲等医院指导下慢性心力衰竭患者的社区管理模式通过提高社区医生对慢性心力衰竭诊治进展及社区疾病管理控制方案的知晓率及执行度,提高患者对慢性心力衰竭的认知率及疾病自我管理能力,改善了患者服药率和遵医行为,有望在远期获得良好的卫生经济学效益.
    목적 건립일개삼급갑등의원지도하만성심력쇠갈환자적사구관리모식.방법 이성도시청양구소파사구화주변신도구성동사구량개구역작위연구기지,입선200례35～85세NYHA심공능분급Ⅱ～Ⅳ급적만성심력쇠갈환자.이가도화소구위기본단원,채용정군수궤분조방법,장기분위간예조(공11개자연거민소구,100례환자)화대조조(공11개자연거민소구,100례환자).삼급갑등의원대청양구소파사구화신도구성동사구의원의생(22명)진행표준화심력쇠갈진치배훈,의생삼여간예조적수방관리;동기대간예조환자진행분차자아관리교육.대조조불진행임하간예.주요수방지표포괄사구의생대심력쇠갈적지효솔、진단양성솔、대표준화치료적접수정도;환자심력쇠갈적지효솔、복약솔、표준화약물사용솔、자아관리능력、생활질량、심혈관사건、주원시간화의료화비.결과 표준화심력쇠갈진치배훈후,사구의생심력쇠갈적지효솔[배훈전후심력쇠갈약물치료화생활지도분별위13.6％(3/22)화100％(22/22),심력쇠갈병인상관방치지식분별위22.7％(5/22)화100％ (22/22)]、진단양성솔[배훈전후분별위51.8％ (100/193)화87.0％(168/193)]、표준화치료접수정도[배훈전후β수체조체제분별위22.7％ (5/22)화77.3％ (17/22),혈관긴장소전환매억제제분별위27.2％ (6/22)화63.6％ (14/22)]균교배훈전증고(P균＜0.05).간예조유효환자96례,대조조유효환자97례.수방시간위(18.5±0.5)개월.간예조환자적질병지효솔[100％(96/96)비71.1％ (69/97)]、복약솔[78.1％ (75/96)비13.4％ (13/97)]、표준화약물사용솔[β수체조체제75.0％(72/96)비8.2％(8/97),혈관긴장소전환매억제제60.4％(58/96)비10.3％(10/97)]、자아일상생활관리솔[한염、공제음식88.5％ (85/96)비29.9％ (23/97)、감측혈압83.3％(80/96)비56.7％ (55/97)、감측체질량78.1％(75/96)비13.4％(13/97)]균고우대조조(P균＜0.05).재61례심공능Ⅲ～Ⅳ급환자중,간예조적생활질량량표총분[(43.7±9.2)분비(49.5±11.3)분]、심혈관사건발생솔[63.3％ (19/30)비90.3％ (28/31)]、주원시간[(8.2 ±3.2)d비(13.9±10.9)d]、주원총비용[(2873.3±401.6)원비(4525.8±6417.8)원]균저우대조조(P균＜0.05).결론 삼급갑등의원지도하만성심력쇠갈환자적사구관리모식통과제고사구의생대만성심력쇠갈진치진전급사구질병관리공제방안적지효솔급집행도,제고환자대만성심력쇠갈적인지솔급질병자아관리능력,개선료환자복약솔화준의행위,유망재원기획득량호적위생경제학효익.
    Objective To establish a community-based management model for heart failure patients under the professional guidance of upper first-class hospital staff.Methods Two hundreds heart failure (New York Heart Function Ⅱ-Ⅳ) patients aged from 35 to 85 in two communities of Chengdu city were divided into two groups by cluster randomization:the management group and the control group.The community hospital doctors were trained for the evaluation and management of heart failure according standardized guidelines by upper first-class hospital doctors,and responsible for the management of patients in the management group.Meanwhile,the management group patients also received self-care education.Patients in control group were treated by community doctors without special training.Data including the community hospital doctors' knowledge rate of heart failure,positive diagnosis rate,and the rate for standardized medication for heart failure; the patients' knowledge rate of heart failure,the rate of drug compliance,the rate of standardized drug taken for heart failure,the rate of self-care in daily-life,the quality of life,the iucidence of cardiovascular events,hospitalization time and cost were compared between the two groups.Results The community hospital doctors' knowledge rate of heart failure,the related knowledge for prevention and treatment on the causes of heart failure,the positive diagnosis rate,and the rate for standardized medication for heart failure [β receptor blocker 77.3％ (17/22); angiotensinconverting enzyme inhibitors 63.6％ (14/22)] were significantly higher than doctors in the control group (all P ＜ 0.05).There were 96 in the management group and 97 in the control group.Data were similar between the two groups at baseline.After (18.5 ± 0.5)months,the patient's knowledge rate of heart failure [100％ (96/96) vs.71.1％ (69/97)],the rate of drug compliance [78.1％ (75/96) vs.13.4％ (13/97)],the rate of standardized drug taken for heart failure[β receptor blocker:75.0％ (72/96) vs.8.2％(8/97) ; angiotensin-converting enzyme inhibitors:60.4％ (58/96) vs.10.3％ (10/97)],and the rate of self-care in daily-life [salt and food restriction:88.5％ (85/96) vs.29.9％ (23/97) ; blood pressure monitoring:83.3％ (80/96) vs.56.7％ (55/97) ; weight monitoring:78.1％ (75/96) vs.13.4％ (13/97)] were all significantly higher in the management group than in control group.For patients with New York Heart Function Ⅲ-Ⅳ,the score of the LiHFe questionnaire (43.7 ± 9.2 vs.49.5 ± 11.3),the incidence of cardiovascular events [63.3％ (19/30) vs.90.3％ (28/31)],the days of hospitalization [(8.2 ± 3.2) days vs.(13.9 ± 10.9) days],and the cost for hospitalization [(2873.3 ± 401.6) Yuan vs.(4525.8 ±6417.8) Yuan] were all significantly lower in the management group(n =30) than in the control group(n =31) (all P ＜ 0.05).Conclusions The community-based management model for heart failure patients in the community level is effective to improve the management and outcome in this cohort.
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