冠状动脉搭桥术后患者随诊管理流程再造

Follow-up management process reengineering in postoperative patients with coronary artery bypass graft

目的总结冠状动脉搭桥术后患者随诊流程再造的运用与效果。方法对入院的单纯行冠状动脉旁路移植术的368例患者，随机分为对照组和随诊流程再造组进行随访研究。对照组按照传统方式随诊，患者依出院医嘱根据自己的实际情况选择复查时间和医院。随诊流程再造组，医生为出院的患者安排康复计划和内容，有指定的社区医疗单位和医生。结果两组患者入院时生活质量及异常血压、血糖、血脂的发生率无差异（P〉0．05）。术后1年，随诊流程再造组和对照组比较，异常血压、血糖、血脂的发生率分别为9．29％、27．04％；6．01％、16．98％；8．74％、22．64％。生活质量评分，随诊流程再造组明显高于对照组（t=2．2439-6．3363，P〈0．05～0．01）。结论随诊流程再造能明显提高冠状动脉搭桥术后患者的生活质量，降低异常血压、血糖、血脂的发生率；社区医疗机构在流程再造中起到了重要作用。

Objective To summarize the application and effect of follow-up management process reengineering in postoperative patients with coronary artery bypass graft （CABG）. Methods Totally, 368 inpatients with CABG were enrolled in this follow-up study. They were randomly divided into control group and follow-up management process reengineering group. In control group, postoperative patients with CABG chose the time and hospital for follow-up by themselves. Patients were initiative, and doctors were passive. In process reengineering group, doctors made a good rehabilitation plan for patients, and community medical unit and doctors were appointed to patients. Doctors were initiative, and patients were passive. Results On admission, the quality of life as well as incidences of abnormal blood pressure, blood sugar and blood fat had no difference between the two groups （P〉0. 05）. At postoperative one year, incidences of abnormal blood pressure, blood sugar and blood fat were 9. 29%, 6. 01%, and 8. 74% in process reengineering group compared with 27. 04%, 16. 98%, and 22. 64% in control group, respectively. The score of quality of life was significantly higher in process reengineering group than that in control group （t=2. 2439-6. 3363,P〈0. 05-0. 01）. Conclusion Follow-up management process reengineering can improve quality of life and lower incidences of abnormal blood pressure, blood sugar and blood fat of postoperative patients with CABG. Community medical unit plays an important role in the follow-up management process reengineering.