基于非住院状态的心力衰竭患者综合管理模式在改善心力衰竭患者预后中的作用研究
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摘要
背景心力衰竭是威胁人类健康的主要疾病之一,尽管心力衰竭治疗药物和手段不断发展,但目前预后并不理想,其中很重要的一个因素是对于慢性心力衰竭患者缺乏院外的准确监测和正规随访。目的建立基于心力衰竭患者非住院状态的综合管理模式,并评估该模式在心力衰竭治疗及预后中的作用。方法选取2016年12月—2017年4月于北京大学人民医院治疗的心力衰竭患者200例,随机分为常规管理组和综合管理组,每组100例。常规管理组患者接受目前临床常规的随诊和治疗。综合管理组患者居家状态下每日自行记录心率、血压、体质量、水肿程度、气促喘憋症状及6 min步行试验结果,根据监测指标调整和制定治疗方案。随访9个月,比较两组患者全因住院率、因心力衰竭再住院率、不良事件发生率、首次住院距入组时间、住院天数、心功能、生活质量评分。分析患者因心力衰竭再住院的影响因素。结果完成随访心力衰竭患者171例,其中常规管理组患者87例,综合管理组患者84例。两组患者性别、年龄、心率、心力衰竭病因比较,差异无统计学意义(P>0.05)。综合管理组全因住院率、因心力衰竭再住院率、平均住院天数低于常规管理组,首次住院距入组时间长于常规管理组,差异有统计学意义(P<0.05)。随访前左心室射血分数(LVEF)、脑钠肽(BNP)水平,第3、6、9个月随访时LVEF比较,差异无统计学意义(P>0.05);第3、6、9个月随访时综合管理组中位BNP低于常规管理组,差异有统计学意义(P<0.05)。随访结束时综合管理组患者日常生活评分、医疗支出评分及生活质量总分低于常规管理组,差异有统计学意义(P<0.05)。逐步Logistic回归分析结果显示,体质量变化、有无气促喘憋症状为患者因心力衰竭再住院的影响因素(P<0.05)。结论基于非住院状态的心力衰竭患者综合管理模式可以降低心力衰竭患者住院率,缩短住院时间,减少不良事件发生率,提高生活质量。体质量变化和气促喘憋症状与患者因心力衰竭再住院有关。
Background Heart failure is one of the major diseases threatening human health.Despite the development of medicines and techniques for the treatment of heart failure,the prognosis is not satisfactory.One of the most important factors is lack of accurate monitoring and regular follow-ups outside the hospital for patients with chronic heart failure.Objective To develop a comprehensive self-management pattern for non-hospitalized heart failure,and to evaluate its effectiveness of treatment and prognostic improvement effect in such patients.Methods The study is designed as a two-group randomized controlled trial.Participants were recruited from Peking University People's Hospital during December 2016 to April 2017 and were equally and randomly assigned to the comprehensive management group(n=100) and control group(n=100).Patients from the control group received regular clinical treatment and follow-ups.Those from comprehensive management group first received selfmanagement training,then measured their heart rate,blood pressure,body weight,evaluated the level of edema,symptoms of short of breath and dyspnea and six-minute walk test(6 MWT) results per day at home and recorded the data by themselves,and the regimen could be adjusted according to their self-reported data by health workers during the follow-ups.The effectiveness of the two intervention patterns was compared in terms of all-cause hospitalization rate,rate of hospitalization due to heart failure,incidence of adverse reactions,duration between the time of starting to receive interventions and first hospitalization,length of stay,cardiac functions and quality of life(evaluated by the Minnesota Living with Heart Failure Questionnaire) during the 9-month follow-up period.And the factors associated with re-hospitalization were analyzed.Results Altogether,171 patients who competed the follow-up were included in the final analysis,including 87 from the control group and 84 from the comprehensive management group.Two groups showed no significant differences in the distribution of sex,and age,average heart rate,and causes of heart failure(P>0.05).Comprehensive management group showed much lower all-cause hospitalization rate,rate of hospitalization due to heart failure and shorter average length of stay,and longer duration between the time of starting to receive interventions and first hospitalization during the follow-up period compared with the control group(P<0.05).The average left ventricular ejection fraction(LVEF) levels at baseline,at the end of the 3 rd,6 th,and 9 th months of intervention were similar in both groups(P>0.05).The average BNP level was similar in both groups at baseline,but the median BNP decreased more significantly in the comprehensive management group instead of the control group at the end of the 3 rd,6 th,and 9 th months of intervention(P>0.05).By the end of the intervention,the average scores of activities of daily living score,medical cost and average total score of quality of life in the comprehensive management group were all much lower than those of the conventional group(P<0.05).Stepwise Logistic regression analysis showed that changes in body weight,and prevalence of short of breath and dyspnea were associated with the rehospitalization(P<0.05).Conclusion The comprehensive selfmanagement can reduce hospitalization rate,shorten the length of stay,decline the incidence of adverse reactions,and improve the quality of life in patients with heart failure.Changes in body weight and shortness of breath were associated with the rehospitalization in this population.
Background Heart failure is one of the major diseases threatening human health.Despite the development of medicines and techniques for the treatment of heart failure,the prognosis is not satisfactory.One of the most important factors is lack of accurate monitoring and regular follow-ups outside the hospital for patients with chronic heart failure.Objective To develop a comprehensive self-management pattern for non-hospitalized heart failure,and to evaluate its effectiveness of treatment and prognostic improvement effect in such patients.Methods The study is designed as a two-group randomized controlled trial.Participants were recruited from Peking University People's Hospital during December 2016 to April 2017 and were equally and randomly assigned to the comprehensive management group(n=100) and control group(n=100).Patients from the control group received regular clinical treatment and follow-ups.Those from comprehensive management group first received selfmanagement training,then measured their heart rate,blood pressure,body weight,evaluated the level of edema,symptoms of short of breath and dyspnea and six-minute walk test(6 MWT) results per day at home and recorded the data by themselves,and the regimen could be adjusted according to their self-reported data by health workers during the follow-ups.The effectiveness of the two intervention patterns was compared in terms of all-cause hospitalization rate,rate of hospitalization due to heart failure,incidence of adverse reactions,duration between the time of starting to receive interventions and first hospitalization,length of stay,cardiac functions and quality of life(evaluated by the Minnesota Living with Heart Failure Questionnaire) during the 9-month follow-up period.And the factors associated with re-hospitalization were analyzed.Results Altogether,171 patients who competed the follow-up were included in the final analysis,including 87 from the control group and 84 from the comprehensive management group.Two groups showed no significant differences in the distribution of sex,and age,average heart rate,and causes of heart failure(P>0.05).Comprehensive management group showed much lower all-cause hospitalization rate,rate of hospitalization due to heart failure and shorter average length of stay,and longer duration between the time of starting to receive interventions and first hospitalization during the follow-up period compared with the control group(P<0.05).The average left ventricular ejection fraction(LVEF) levels at baseline,at the end of the 3 rd,6 th,and 9 th months of intervention were similar in both groups(P>0.05).The average BNP level was similar in both groups at baseline,but the median BNP decreased more significantly in the comprehensive management group instead of the control group at the end of the 3 rd,6 th,and 9 th months of intervention(P>0.05).By the end of the intervention,the average scores of activities of daily living score,medical cost and average total score of quality of life in the comprehensive management group were all much lower than those of the conventional group(P<0.05).Stepwise Logistic regression analysis showed that changes in body weight,and prevalence of short of breath and dyspnea were associated with the rehospitalization(P<0.05).Conclusion The comprehensive selfmanagement can reduce hospitalization rate,shorten the length of stay,decline the incidence of adverse reactions,and improve the quality of life in patients with heart failure.Changes in body weight and shortness of breath were associated with the rehospitalization in this population.
引文
[1]林施峰,李世阁,林基表,等.左西孟旦对扩张型心肌病慢性心力衰竭患者心功能的影响及疗效观察[J].安徽医学,2018,39(11):1339-1343.DOI:10.3969/j.issn.1000-0399.2018.11.012.LIN S F,LI S G,LIN J B,et al.Effect of levosimendan on cardiac function in patients with dilated cardiomyopathy and chronic heart failure[J].Anhui Medical Journal,2018,39(11):1339-1343.DOI:10.3969/j.issn.1000-0399.2018.11.012.
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[3]CICCONE M M,AQUILINO A,CORTESE F,et al.Feasibility and effectiveness of a disease and care management model in the primary health care system for patients with heart failure and diabetes(Project Leonardo)[J].Vascular Health and Risk Management,2010,6(1):297-305.DOI:10.2147/VHRM.S9252.
[4]李小华,代艳.慢性心力衰竭患者实施自我管理的效果[J].中华现代护理学杂志,2012,47(2):176-178.DOI:10.3761/j.issn.0254-1769.2012.02.031.LI X H,DAI Y.Effect of self-management in patients with chronic heart failure[J].Journal of Modern Nursing,2012,47(2):176-178.DOI:10.3761/j.issn.0254-1769.2012.02.031.
[5]陈爽,焦雪峰,郭蕊.临床药师参与慢性心力衰竭疾病管理的效果评价[J].中国药房,2016,27(35):5021-5023.DOI:10.6039/j.issn.1001-0408.2016.35.42.CHEN S,JIAO X F,GUO R.Effects evaluation of clinical pharmacists participating in disease management of chronic heart failure[J].China Pharmacy,2016,27(35):5021-5023.DOI:10.6039/j.issn.1001-0408.2016.35.42.
[6]谢霜,周苔花,朱萍.慢性心力衰竭患者生活质量的影响因素研究[J].实用心脑肺血管病杂志,2017,25(5):32-35.DOI:10.3969/j.issn.1008-5971.2017.05.009.XIE S,ZHOU T H,ZHU P.Influencing factors of quality of life in patients with chronic heart failure[J].Practical Journal of Cardiac Cerebral Pneumal and Vascular Disease,2017,25(5):32-35.DOI:10.3969/j.issn.1008-5971.2017.05.009.
[7]杨蕾,钟林华,叶薇,等.延续性护理对慢性心力衰竭患者自护行为及预后的影响[J].实用心脑肺血管病杂志,2017,25(12):114-115.YANG L,ZHONG L H,YE W,et al.Influence of continuous nursing on self-care behaviors and prognosis of chronic heart failure patients[J].Practical Journal of Cardiac Cerebral Pneumal and Vascular Disease,2017,25(12):114-115.
[8]吴学思.2009美国《成人心力衰竭诊疗指南更新》解读[J].中华内科杂志,2009,48(10):807-808.DOI:10.3760/cma.j.issn.0578-1426.2009.10.006.WU X S.Forum of internal medicine unscramble american heart failure guideline 2009[J].Chinese Journal of Internal Medicine,2009,48(10):807-808.DOI:10.3760/cma.j.issn.0578-1426.2009.10.006.
[9]BILBAO A,ESCOBAR A,GARCíA-PEREZ L,et al.The Minnesota living with heart failure questionnaire:comparison of different factor structures[J].Health and Quality of Life Outcomes,2016,14(1):23.DOI:10.1186/s12955-016-0425-7.
[10]周京敏,崔晓通,葛均波.中国心力衰竭的流行病学概括[J].中华心血管病杂志,2015,12(43):1018-1021.DOI:10.3760/cma.j.issn.0253-3758.2015.12.002.ZHOU J M,CUI X T,GE J B.Epidemiological summary of heart failure in China[J].Chinese Journal of Cardiology,2015,12(43):1018-1021.DOI 10.3760/cma.j.issn.0253-3758.2015.12.002.
[11]李卉,赵彬,安舜禹,等.美国社区卫生服务体系现状及启示[J].中国公共卫生,2012,28(2):183-184.DOI:10.11847/zgggws-2012-28-02-24.LI H,ZHAO B,AN S Y,et al.Current situation and enlightenment of american community health service system[J].Chinese Journal of Public Health,2012,28(2):183-184.DOI:10.11847/zgggws-2012-28-02-24.
[12]PASCUAL C R,GALáN E P,GUERRERO J L,et al.Rationale and methods of the multicenter randomised trial of a heart failure management programme among geriatric patients(HF-Geriatrics)[J].BMC Public Health,2011,11:627.DOI:10.1186/1471-2458-11-627.
[13]张振财.对慢性心力衰竭患者院内外随访管理的效果评价[J].吉林医学,2013,34(23):4835.DOI:10.3969/j.issn.1004-0412.2013.23.179.ZHANG Z C.Evaluation of the effect of follow-up management in and out of hospital for patients with chronic heart failure[J].Jilin Medical Journal,2013,34(23):4835.DOI:10.3969/j.issn.1004-0412.2013.23.179.
[14]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.慢性心力衰竭诊断治疗指南[J].中华心血管病杂志,2007,35(12):1076-1095.Chinese Society of Cardiology,Editorial Board of Chinese Journal of Cardiovascular Disease.Guidelines for the diagnosis and management of chronic heart failure[J].Chinese Journal of Cardiology,2007,35(12):1076-1095.
[15]路海棠.心力衰竭患者左室增大与心功能及室性心律失常的关系[J].安徽医学,2017,38(2):181-184.DOI:10.3969/j.issn.1000-0399.2017.02.015.LU H T.Relationship of left ventricular enlargement with cardiac function and ventricular arrhythmia[J].Anhui Medical Journal,2017,38(2):181-184.DOI:10.3969/j.issn.1000-0399.2017.02.015.
[16]CHENG J W,NAYAR M.A review of heart failure management in the elderly population[J].Am J Geriatr Pharmacother,2009,7(5):233-249.DOI:10.1016/j.amjopharm.2009.10.001.
[17]KAPRANA M,DEATON C,CARESS A,et al.Do functional class and psychological status predict self-care in non-ischaemic heart failure patients?[J].European Journal of Cardiovascular Nursing,2011,10(1):s28.DOI:10.1016/S1474-5151(11)60103-5.
[18]王斯佳,王国干.急性心力衰竭患者一年心血管死亡或心力衰竭再住院独立危险因素分析[J].中国循环杂志,2016,31(z1):53.DOI:10.3969/j.issn.1000-3614.2016.z1.150.WANG S J,WANG G G.Analysis of independent risk factors for cardiovascular death or heart failure rehospitalization in patients with acute heart failure in one year[J].Chinese Circulation Journal,2016,31(z1):53.DOI:10.3969/j.issn.1000-3614.2016.z1.150.
[2]何显菁.心力衰竭发病机制、诊断及治疗的研究进展[J].实用心脑肺血管病杂志,2018,26(7):1-8.DOI:10.3669/j.issn.1008-5971.2018.01.001.HE X J.Research progress in pathogenesis,diagnosis and treatment of heart failure[J].Practical Journal of Cardiac Cerebral Pneumal and Vascular Disease,2018,26(7):1-8.DOI:10.3669/j.issn.1008-5971.2018.01.001.
[3]CICCONE M M,AQUILINO A,CORTESE F,et al.Feasibility and effectiveness of a disease and care management model in the primary health care system for patients with heart failure and diabetes(Project Leonardo)[J].Vascular Health and Risk Management,2010,6(1):297-305.DOI:10.2147/VHRM.S9252.
[4]李小华,代艳.慢性心力衰竭患者实施自我管理的效果[J].中华现代护理学杂志,2012,47(2):176-178.DOI:10.3761/j.issn.0254-1769.2012.02.031.LI X H,DAI Y.Effect of self-management in patients with chronic heart failure[J].Journal of Modern Nursing,2012,47(2):176-178.DOI:10.3761/j.issn.0254-1769.2012.02.031.
[5]陈爽,焦雪峰,郭蕊.临床药师参与慢性心力衰竭疾病管理的效果评价[J].中国药房,2016,27(35):5021-5023.DOI:10.6039/j.issn.1001-0408.2016.35.42.CHEN S,JIAO X F,GUO R.Effects evaluation of clinical pharmacists participating in disease management of chronic heart failure[J].China Pharmacy,2016,27(35):5021-5023.DOI:10.6039/j.issn.1001-0408.2016.35.42.
[6]谢霜,周苔花,朱萍.慢性心力衰竭患者生活质量的影响因素研究[J].实用心脑肺血管病杂志,2017,25(5):32-35.DOI:10.3969/j.issn.1008-5971.2017.05.009.XIE S,ZHOU T H,ZHU P.Influencing factors of quality of life in patients with chronic heart failure[J].Practical Journal of Cardiac Cerebral Pneumal and Vascular Disease,2017,25(5):32-35.DOI:10.3969/j.issn.1008-5971.2017.05.009.
[7]杨蕾,钟林华,叶薇,等.延续性护理对慢性心力衰竭患者自护行为及预后的影响[J].实用心脑肺血管病杂志,2017,25(12):114-115.YANG L,ZHONG L H,YE W,et al.Influence of continuous nursing on self-care behaviors and prognosis of chronic heart failure patients[J].Practical Journal of Cardiac Cerebral Pneumal and Vascular Disease,2017,25(12):114-115.
[8]吴学思.2009美国《成人心力衰竭诊疗指南更新》解读[J].中华内科杂志,2009,48(10):807-808.DOI:10.3760/cma.j.issn.0578-1426.2009.10.006.WU X S.Forum of internal medicine unscramble american heart failure guideline 2009[J].Chinese Journal of Internal Medicine,2009,48(10):807-808.DOI:10.3760/cma.j.issn.0578-1426.2009.10.006.
[9]BILBAO A,ESCOBAR A,GARCíA-PEREZ L,et al.The Minnesota living with heart failure questionnaire:comparison of different factor structures[J].Health and Quality of Life Outcomes,2016,14(1):23.DOI:10.1186/s12955-016-0425-7.
[10]周京敏,崔晓通,葛均波.中国心力衰竭的流行病学概括[J].中华心血管病杂志,2015,12(43):1018-1021.DOI:10.3760/cma.j.issn.0253-3758.2015.12.002.ZHOU J M,CUI X T,GE J B.Epidemiological summary of heart failure in China[J].Chinese Journal of Cardiology,2015,12(43):1018-1021.DOI 10.3760/cma.j.issn.0253-3758.2015.12.002.
[11]李卉,赵彬,安舜禹,等.美国社区卫生服务体系现状及启示[J].中国公共卫生,2012,28(2):183-184.DOI:10.11847/zgggws-2012-28-02-24.LI H,ZHAO B,AN S Y,et al.Current situation and enlightenment of american community health service system[J].Chinese Journal of Public Health,2012,28(2):183-184.DOI:10.11847/zgggws-2012-28-02-24.
[12]PASCUAL C R,GALáN E P,GUERRERO J L,et al.Rationale and methods of the multicenter randomised trial of a heart failure management programme among geriatric patients(HF-Geriatrics)[J].BMC Public Health,2011,11:627.DOI:10.1186/1471-2458-11-627.
[13]张振财.对慢性心力衰竭患者院内外随访管理的效果评价[J].吉林医学,2013,34(23):4835.DOI:10.3969/j.issn.1004-0412.2013.23.179.ZHANG Z C.Evaluation of the effect of follow-up management in and out of hospital for patients with chronic heart failure[J].Jilin Medical Journal,2013,34(23):4835.DOI:10.3969/j.issn.1004-0412.2013.23.179.
[14]中华医学会心血管病学分会,中华心血管病杂志编辑委员会.慢性心力衰竭诊断治疗指南[J].中华心血管病杂志,2007,35(12):1076-1095.Chinese Society of Cardiology,Editorial Board of Chinese Journal of Cardiovascular Disease.Guidelines for the diagnosis and management of chronic heart failure[J].Chinese Journal of Cardiology,2007,35(12):1076-1095.
[15]路海棠.心力衰竭患者左室增大与心功能及室性心律失常的关系[J].安徽医学,2017,38(2):181-184.DOI:10.3969/j.issn.1000-0399.2017.02.015.LU H T.Relationship of left ventricular enlargement with cardiac function and ventricular arrhythmia[J].Anhui Medical Journal,2017,38(2):181-184.DOI:10.3969/j.issn.1000-0399.2017.02.015.
[16]CHENG J W,NAYAR M.A review of heart failure management in the elderly population[J].Am J Geriatr Pharmacother,2009,7(5):233-249.DOI:10.1016/j.amjopharm.2009.10.001.
[17]KAPRANA M,DEATON C,CARESS A,et al.Do functional class and psychological status predict self-care in non-ischaemic heart failure patients?[J].European Journal of Cardiovascular Nursing,2011,10(1):s28.DOI:10.1016/S1474-5151(11)60103-5.
[18]王斯佳,王国干.急性心力衰竭患者一年心血管死亡或心力衰竭再住院独立危险因素分析[J].中国循环杂志,2016,31(z1):53.DOI:10.3969/j.issn.1000-3614.2016.z1.150.WANG S J,WANG G G.Analysis of independent risk factors for cardiovascular death or heart failure rehospitalization in patients with acute heart failure in one year[J].Chinese Circulation Journal,2016,31(z1):53.DOI:10.3969/j.issn.1000-3614.2016.z1.150.