CAJ | 학술논문

目的：：建立慢性心力衰竭患者出院后的疾病管理方案，观察疾病管理对患者预后的影响。方法：入选慢性心衰力竭急性加重住院患者207例，出院后随机分为研究组103例和对照组104例，研究组采取疾病管理方案，对照组仅进行常规门诊随访，比较两组出院后1年时的临床随访结果。结果：排除失访患者，共188例获得完整资料，其中研究组98例，对照组90例，两组基线临床特征差异无统计学意义(P >0.05)。随访结果显示，与对照组比较，研究组出院后6个月内再入院率、多次再入院率、再入院或死亡联合事件发生率均明显降低(P <0.05)。研究组心功能 I 或 II 级患者所占百分比、左室射血分数均高于对照组(P <0.05)，左室舒张期末径小于对照组(P <0.05)。研究组明尼苏达心衰生活质量评分优于对照组(P <0.05)。结论：对慢性心力衰竭患者出院后实施疾病管理可显著降低患者出院后6个月再入院、多次再入院以及再入院或死亡联合事件的发生风险，并改善患者的心功能和生活质量。
목적：：건립만성심력쇠갈환자출원후적질병관리방안，관찰질병관리대환자예후적영향。방법：입선만성심쇠력갈급성가중주원환자207례，출원후수궤분위연구조103례화대조조104례，연구조채취질병관리방안，대조조부진행상규문진수방，비교량조출원후1년시적림상수방결과。결과：배제실방환자，공188례획득완정자료，기중연구조98례，대조조90례，량조기선림상특정차이무통계학의의(P >0.05)。수방결과현시，여대조조비교，연구조출원후6개월내재입원솔、다차재입원솔、재입원혹사망연합사건발생솔균명현강저(P <0.05)。연구조심공능 I 혹 II 급환자소점백분비、좌실사혈분수균고우대조조(P <0.05)，좌실서장기말경소우대조조(P <0.05)。연구조명니소체심쇠생활질량평분우우대조조(P <0.05)。결론：대만성심력쇠갈환자출원후실시질병관리가현저강저환자출원후6개월재입원、다차재입원이급재입원혹사망연합사건적발생풍험，병개선환자적심공능화생활질량。
Objective:To establish the post-discharge disease management program for patients with chronic heart failure,and observe the effects of disease management on prognosis.Methods:Totally 207 patients with chronic heart failure,who were ad-mitted to hospital due to acute exacerbation,were enrolled.After discharge these patients were randomly divided into the study group (103 cases)and the control group (104 cases).Disease management program was implemented in the study group,and only routine outpatient follow-up was implemented in the control group.The clinical follow-up results one year after discharge were compared between the two groups.Results:Excluding the patients lost during follow-up,totally 1 88 patients completed the data collection,among which 98 cases were from the study group and 90 cases were from the control group.There was no significant difference regarding the baseline of clinical characteristics between the two groups (P >0.05 ).Follow-up results showed that compared with that in the control group,within the six months after discharged,the readmission rate,the multi-ple readmission rate,and the readmission or death joint events rate in the study group decreased significantly (P <0.05).The percentage of cardiac function NYHA class I to II and the left ventricular ejection fraction in the study group were higher than that in the control group (P <0.05),and the left ventricular end-diastolic diameter was in contrast (P <0.05).The score of Minnesota Living with Heart Failure Questionnaire in the study group was superior to that in the control group (P <0.05 ). Conclusions:The implementation of post-discharge disease management for the patients with chronic heart failure can signifi-cantly reduce the risk of the readmission,the multiple readmission,and the readmission or death joint events within the six months after discharge,and improve the patients’cardiac function and quality of life.