双向联动疾病管理模式在社区慢性心衰高危人群中的应用及效果评价
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摘要
目的探讨双向联动疾病管理模式在社区慢性心力衰竭高危人群中的应用效果。方法从高行健康体检中心筛检出240例心衰高危病例,采用随机数字法分为干预组和对照组。干预组由高行社区和上级医院组建的多学科联合管理团队对心衰高危人群按照双向联动疾病管理模式干预,对照组由不参与本研究的全科团队按照社区常规慢性病管理模式进行随访和干预指导,及时做好随访记录,2年后进行效果评价。结果两组干预前后在疾病知识、日常生活管理、依从性和生活质量方面均有很大程度的提高(P<0.05),且干预后干预组显著高于对照组,差异均有统计学意义(P<0.01)。两组的心衰新发例数比较差异无统计学意义(P>0.05)。结论医院-社区双向联动管理模式可以提高患者对疾病的认知率、对家庭医生的依从性和日常自我管理能力,改善患者生活质量,有效减少心衰B期、C期和D期的新发病例数,为心衰高危人群的早期干预提供新思路,为社区慢性病管理提供参考依据。
OBJECTIVE To evaluate the application and evaluation of two-way linkage disease management in high risk community patients with chronic heart failure. METHODS It researched 240 patients having chronic heart failure in level A. With methods of random grouping,the patients were divided into intervention group and control group. The intervention group was managed by united teamwork,meanwhile,the control group was managed by the community hospital doctor who did not take part in this research. It collected the data on follow-up and intervention guidance. After two years,it would evaluate the effect. RESULTS Two groups greatly improved disease knowledge,daily life management,compliance and quality of life after interention(P<0.05). There was statistical significance between intervention group and control group(P<0.01). The intervention group had lower incidence of chronicheart failure than the control group.CONCLUSION The two-way linkage disease management could improve the patient's awareness of the disease,improve the quality of life of patients,so as to reduce complications of chronic heart failure in level B,C,D,to provide new thoughts in high risk community patients with chronic heart failure,which could supply basis for community chronic diseases management.
OBJECTIVE To evaluate the application and evaluation of two-way linkage disease management in high risk community patients with chronic heart failure. METHODS It researched 240 patients having chronic heart failure in level A. With methods of random grouping,the patients were divided into intervention group and control group. The intervention group was managed by united teamwork,meanwhile,the control group was managed by the community hospital doctor who did not take part in this research. It collected the data on follow-up and intervention guidance. After two years,it would evaluate the effect. RESULTS Two groups greatly improved disease knowledge,daily life management,compliance and quality of life after interention(P<0.05). There was statistical significance between intervention group and control group(P<0.01). The intervention group had lower incidence of chronicheart failure than the control group.CONCLUSION The two-way linkage disease management could improve the patient's awareness of the disease,improve the quality of life of patients,so as to reduce complications of chronic heart failure in level B,C,D,to provide new thoughts in high risk community patients with chronic heart failure,which could supply basis for community chronic diseases management.
引文
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[9]HUNT S A.American College of Cardiology,American Heart As-sociation Task Force on Practice Guidelines.ACC/AHA 2005guideline update for the diagnosis and management of chronicheart failure in the adult:a report of the American College of Car-diology/American Heart Association Task Force on Practice Guide-lines(Writing Committee to Update the 2001 Guidelines for theEvaluation and Management of Heart Failure)[J].J am coll cardi-ol,2005,46(6):1-82.
[10]2009 Focused Update Incorporated Into the ACC/AHA 2005.Guidelines for the Diagnosis and Management of Heart Failure inAdults[J].J Am Coll Cardiol,2009(53):1-90.
[11]谢会会,沈彬,王红梅,等.社区-家庭管理模式应用于慢性心力衰竭患者的效果观察[J].浙江临床医学,2013,15(8):1227-1228.
[12]黎慧莲,王利玲,叶小宁.慢性心力衰竭从医院到社区无缝隙护理管理模式的应用[J].社区医学杂志,2014,12(24):20-21.
[2]HUNT S A,ABRAHAM W T,CHIN M H,et al.2009 FocusedUpdate Incorporated Into the ACC/AHA 2005.Guidelines for theDiagnosis and Management of Heart Failure in Adults[J].J AmColl Cardiol 2009,(53):1-90.
[3]GOHLER A,JAMES LJ,Stewart S W,et al.A systematic meta-analysis of the efficacy and heterogeneity of disease managementprogram in congestive heart failure[J].J card fail,2006,12(7):554-567.
[4]GREGORY D,KIMMELSTIEL C,PERRY K,et al.Hospitalcost effect of a heart failure disease management program:the spe-cialized primary and networked care in heart failure(SPSN-CHF)trial[J].Am heart j,2006(151):1013-1018.
[5]MOSTERD A,HOES A W.Clinical epidemiology of heart failure[J].Heart,2007,93(9):1137-1146.
[6]费大东,土晓梅,邓莉,等.2型糖尿病患者心血管风险评估及社区综合干预临床观察[J].山东医药,2011,11(5):51-52.
[7]GIAMOUZIS G,KALOGEROPULOS A,GEORGIOPOULOU V,et al.Hospitalization epidemic in patients with heart failure:riskfactors,risk prediction,knowledge gaps,and future directions[J].J card fail,2011,17(1):54-57.
[8]HE J,OGDEN L G,BAZZANO L A,et al.Risk factors for con-gestive heart failure in US men and women;NHANES I epidemio-logic follow-up study[J].Arch intern med,2001,161(7):996-1002.
[9]HUNT S A.American College of Cardiology,American Heart As-sociation Task Force on Practice Guidelines.ACC/AHA 2005guideline update for the diagnosis and management of chronicheart failure in the adult:a report of the American College of Car-diology/American Heart Association Task Force on Practice Guide-lines(Writing Committee to Update the 2001 Guidelines for theEvaluation and Management of Heart Failure)[J].J am coll cardi-ol,2005,46(6):1-82.
[10]2009 Focused Update Incorporated Into the ACC/AHA 2005.Guidelines for the Diagnosis and Management of Heart Failure inAdults[J].J Am Coll Cardiol,2009(53):1-90.
[11]谢会会,沈彬,王红梅,等.社区-家庭管理模式应用于慢性心力衰竭患者的效果观察[J].浙江临床医学,2013,15(8):1227-1228.
[12]黎慧莲,王利玲,叶小宁.慢性心力衰竭从医院到社区无缝隙护理管理模式的应用[J].社区医学杂志,2014,12(24):20-21.