摘要
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B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。
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 incidence 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-eonverting 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.
出处
《中华心血管病杂志》
CAS
CSCD
北大核心
2012年第11期939-944,共6页
Chinese Journal of Cardiology
基金
成都市“十一五”科技攻关重大项目（07YTYB957SF-020）
关键词
心力衰竭
充血性
疾病管理
社区医学
Heart failure, congestive
Disease management
Community medicine
