社区与家庭一体化管理模式在农村地区冠心病二级预防中的探索
|
摘要
目的探索建立一种以助理全科医师为主体,社区卫生服务中心与患者家庭对冠心病出院患者进行连续性管理,适合现阶段农村基层医疗卫生条件的冠心病二级预防新模式。方法将2016年6月—2017年6月在北京市延庆区医院确诊的100例冠心病患者作为实验组纳入"社区与家庭一体化管理"模式进行冠心病二级预防管理并随访12个月,回顾前1年(2015年6月—2016年6月)在北京市延庆区医院确诊的100例冠心病患者二级预防效果为对照组,就2组患者对冠心病知识知晓率(问卷调查)、循证药物治疗的依从性(家属对患者服药种类及次数进行记录)、冠心病危险因素(每3个月测量1次血压、血糖、血脂、体重及戒烟率)的控制及不良心血管事件发生率进行对比研究。结果经"社区与家庭一体化管理"模式进行冠心病二级预防的患者,对冠心病知识掌握率为74%(对照组为38%)、服药依从性为88%(对照组为46%)均明显提高(均P<0.05);吸烟、控制体重等不良生活方式改善不明显(P>0.05),低密度脂蛋白、血压、血糖等指标较入院时显著改善(均P<0.05),2组不良心血管事件发生率比较差异无统计学意义(P>0.05)。结论 "社区与家庭一体化管理"冠心病二级预防模式保障了对出院患者的连续性管理,明显提升冠心病患者对所患疾病的认识,有效控制冠心病危险因素,提高循症药物治疗的依从性。
Objective To explore and establish a new mode of secondary prevention of coronary heart disease with assistant general practitioners as the main body, community health service centers and patients' family members conducting continuous management of coronary heart disease discharged patients, which is suitable for the current rural grassroots medical and health conditions. Methods A total of 100 cases of coronary heart disease patients diagnosed in Beijing Yanqing district hospital from June 2016 to June 2017 were selected as experimental group into "the integration of community and family management" model for secondary prevention of coronary heart disease management and follow-up of 12 months. A review was made of 100 cases of coronary heart disease(CHD) patients with secondary prevention effect 1 year earlier(from June 2015 to June 2016) treated in Beijing Yanqing district hospital who was selected as the control group. A comparative analysis was made regarding to coronary heart disease knowledge awareness(questionnaire) and evidence-based medicine compliance(families of patients with medication type and number of records), coronary heart disease risk factors(every 3 months 1 time of blood pressure measurement), the control of blood glucose, lipids, body weight and smoking cessation rate and the incidence of adverse cardiovascular events. Results Via the "integration of community and family management" model for secondary prevention of coronary artery disease patients, 74%(control, 38%) for coronary heart disease knowledge rate, medication adherence by 88%(control, 46%) were significantly increased(P<0.05); smoking, control weight and lifestyle improvement were not obvious(P>0.05); low density lipoprotein, blood pressure, blood glucose were significantly improved(all P<0.05). There was no significant difference in the incidence of adverse cardiovascular events between the two groups(P>0.05). Conclusion The "integrated community and family management" mode of secondary prevention of coronary heart disease ensures the continuous management of discharged patients, significantly improves the awareness of patients with coronary heart disease, effectively controls the risk factors of coronary heart disease, and improves the compliance of evidence-based drug treatment.
Objective To explore and establish a new mode of secondary prevention of coronary heart disease with assistant general practitioners as the main body, community health service centers and patients' family members conducting continuous management of coronary heart disease discharged patients, which is suitable for the current rural grassroots medical and health conditions. Methods A total of 100 cases of coronary heart disease patients diagnosed in Beijing Yanqing district hospital from June 2016 to June 2017 were selected as experimental group into "the integration of community and family management" model for secondary prevention of coronary heart disease management and follow-up of 12 months. A review was made of 100 cases of coronary heart disease(CHD) patients with secondary prevention effect 1 year earlier(from June 2015 to June 2016) treated in Beijing Yanqing district hospital who was selected as the control group. A comparative analysis was made regarding to coronary heart disease knowledge awareness(questionnaire) and evidence-based medicine compliance(families of patients with medication type and number of records), coronary heart disease risk factors(every 3 months 1 time of blood pressure measurement), the control of blood glucose, lipids, body weight and smoking cessation rate and the incidence of adverse cardiovascular events. Results Via the "integration of community and family management" model for secondary prevention of coronary artery disease patients, 74%(control, 38%) for coronary heart disease knowledge rate, medication adherence by 88%(control, 46%) were significantly increased(P<0.05); smoking, control weight and lifestyle improvement were not obvious(P>0.05); low density lipoprotein, blood pressure, blood glucose were significantly improved(all P<0.05). There was no significant difference in the incidence of adverse cardiovascular events between the two groups(P>0.05). Conclusion The "integrated community and family management" mode of secondary prevention of coronary heart disease ensures the continuous management of discharged patients, significantly improves the awareness of patients with coronary heart disease, effectively controls the risk factors of coronary heart disease, and improves the compliance of evidence-based drug treatment.
引文
[1] JOAN B,SORIANO J,AMANUEL ALEMU A,et al.A systematic analysis for the Global Burden of Disease Study 2015[J].Lancet,2016,388(10053):1603-1658.
[2] 中国心血管病预防指南(2017)写作组,中华心血管病杂志编辑委员会.《中国心血管病预防指南(2017)》冠心病二级预防要点[J].实用心脑肺血管病杂志,2018,26(1):6.
[3] 中华医学会心血管病学分会,中国康复医学会心血管病专业委员会,中国老年学学会心脑血管病专业委员会,等.冠心病康复与二级预防中国专家共识[J].中国心血管病杂志,2013,11(4):110-115.
[4] 杨玉琴.冠心病二级预防中降脂药物服用及血脂水平控制危险因素调查研究[J].心血管病防治知识(学术版),2018(14):3-5.
[5] 陈伟伟,高润霖,刘力生,等.《中国心血管病报告2017》概要[J].中国循环杂志,2018,33 (1):1-8.
[6] ERGATOUDES C,THUNSTROM E,ROSENGREN A,et al.Long-term secondary prevention of acute myocardial infarction(SEPAT)-guidelines adherence and outcome[J].BMC Cardiovasc Disord,2016,16(1):226.
[7] 和健洋.优化护理流程对冠心病患者遵医行为及预后的影响[J].中华全科医学,2017,15(9):1620-1622.
[8] 金钟一,皮林,韩海英,等.家庭运动康复对于冠状动脉介入术后患者心肺功能的影响[J].慢性病学杂志,2018,19(7):838-840,843.
[9] YUSUF S,ISLAN S,CHOWC K,et al.Use of second aryprevention drugs for cardiovascular disease in the community in high-income,middle-income,and low-income countries(the PURE study):a prospective epidemiological survery[J].Lancet,2011,378(9798):1231-1243.
[10] 马艳.老年冠心病患者二级预防用药依从性及影响因素的调查[D].合肥:安徽医科大学,2018.
[11] 王高频,刘国銮,杨雪佳,等.冠心病患者二级预防规范化治疗效果随访研究[J].中国全科医学,2012,15(8):831-833.
[12] 黄子菁,曹洋.论戒烟在冠心病二级预防中的重要性[J].实用心脑肺血管病杂志,2015,23(1):138-140.
[13] 孙金栋,袁红,於华敏,等.冠心病合并代谢综合征患者脂联素水平与炎症因子及冠状动脉病变的关系[J].中华全科医学,2016,14(6):918-920.
[14] 吴国星,徐步红.基层医院冠心病二级预防《指南》的遵循度[J].心脑血管病防治,2013,13(1):55-57.
[15] 吴文佳.家庭医生制度下社区冠心病心脏康复管理模式的构想[J].中国社区医师,2018,34(1):7-8,11.
[2] 中国心血管病预防指南(2017)写作组,中华心血管病杂志编辑委员会.《中国心血管病预防指南(2017)》冠心病二级预防要点[J].实用心脑肺血管病杂志,2018,26(1):6.
[3] 中华医学会心血管病学分会,中国康复医学会心血管病专业委员会,中国老年学学会心脑血管病专业委员会,等.冠心病康复与二级预防中国专家共识[J].中国心血管病杂志,2013,11(4):110-115.
[4] 杨玉琴.冠心病二级预防中降脂药物服用及血脂水平控制危险因素调查研究[J].心血管病防治知识(学术版),2018(14):3-5.
[5] 陈伟伟,高润霖,刘力生,等.《中国心血管病报告2017》概要[J].中国循环杂志,2018,33 (1):1-8.
[6] ERGATOUDES C,THUNSTROM E,ROSENGREN A,et al.Long-term secondary prevention of acute myocardial infarction(SEPAT)-guidelines adherence and outcome[J].BMC Cardiovasc Disord,2016,16(1):226.
[7] 和健洋.优化护理流程对冠心病患者遵医行为及预后的影响[J].中华全科医学,2017,15(9):1620-1622.
[8] 金钟一,皮林,韩海英,等.家庭运动康复对于冠状动脉介入术后患者心肺功能的影响[J].慢性病学杂志,2018,19(7):838-840,843.
[9] YUSUF S,ISLAN S,CHOWC K,et al.Use of second aryprevention drugs for cardiovascular disease in the community in high-income,middle-income,and low-income countries(the PURE study):a prospective epidemiological survery[J].Lancet,2011,378(9798):1231-1243.
[10] 马艳.老年冠心病患者二级预防用药依从性及影响因素的调查[D].合肥:安徽医科大学,2018.
[11] 王高频,刘国銮,杨雪佳,等.冠心病患者二级预防规范化治疗效果随访研究[J].中国全科医学,2012,15(8):831-833.
[12] 黄子菁,曹洋.论戒烟在冠心病二级预防中的重要性[J].实用心脑肺血管病杂志,2015,23(1):138-140.
[13] 孙金栋,袁红,於华敏,等.冠心病合并代谢综合征患者脂联素水平与炎症因子及冠状动脉病变的关系[J].中华全科医学,2016,14(6):918-920.
[14] 吴国星,徐步红.基层医院冠心病二级预防《指南》的遵循度[J].心脑血管病防治,2013,13(1):55-57.
[15] 吴文佳.家庭医生制度下社区冠心病心脏康复管理模式的构想[J].中国社区医师,2018,34(1):7-8,11.
© 2004-2018 中国地质图书馆版权所有 京ICP备05064691号 京公网安备11010802017129号 地址：北京市海淀区学院路29号 邮编：100083 电话：办公室：(+86 10)66554848；文献借阅、咨询服务、科技查新：66554700 |