社区医疗单位参与搭桥术后患者健康管理的探讨

Approaching Community Medical Therapy Unit Participating in Health Management to Postoperative Patients with Coronary Artery Bypass Graft

探讨"大医院医生—社区医疗单位—患者"点对点管理中,社区医疗单位参与冠状动脉搭桥术后患者健康管理的实施与效果。冠状动脉搭桥手术患者503例,随机分为对照组和健康管理组进行随访研究,阐述了冠状动脉搭桥手术患者的特点、社区医疗单位的概念、健康管理流程再造与效果、社区医疗单位的管理内容等,与传统的随诊模式比较,认为在大医院主管医生的参与下,社区医疗单位完全可以最有效地承担冠状动脉搭桥术后患者的健康管理和干预措施。

To evaluate the effect of Community Medical Therapy Unit （CMTU） participating in health management, which is site to site on big hospital doctor, CMTU and patient, to postoperative patients with Coronary Artery Bypass Graft （CABG） .Five hundreds and three patients with CABG, divided into health management group and control group, were undergone follow-up studies.These patients＂ feature, concept of CMTU, health management process reengineering, content of management in CMTU was explained.in conclusion, CMTU could assume effectively the follow-up health management and intervention of postoperative patients with CABG under big hospital doctor＇s participating.