老年冠心病患者经皮冠状动脉介入术后社区随访研究

Follow-up Research on the Community Senile Coronary Heart Disease Patients Treated with PCI

目的了解并分析北京市月坛社区老年冠心病患者接受经皮冠状动脉介入术(PCI)治疗后在社区接受全科医生连续性健康管理的情况,为进一步提高冠心病PCI后患者社区管理水平提供经验。方法从2008年5月—2009年12月在北京市月坛社区≥60岁的老年冠心病患者中连续入选已知接受PCI术后半年及以上患者62例作为研究对象。采用问卷调查及病例回顾性调查研究方法,通过自行设计的调查问卷收集患者的基本情况、社区随诊情况、药物治疗情况、相关合并症治疗控制情况等资料,并采用SF-36量表进行生活质量评估。结果 62例老年冠心病PCI术后患者中,56.45%的患者因冠心病PCI术后每月到社区就诊1次,69.35%的患者每1～3个月到社区就诊1次;在过去1年中接受全科医生与专科医生双向转诊人数18人(29.03%),共21人次;老年冠心病患者PCI术后半年内规律服药率较高,而1年以后随访各药物规律服用率略有下降趋势,其中他汀类药物的规律服用率降低较明显。合并高血压者53例,血压控制达标率为83.02%;合并糖尿病29例,血糖控制达标率为62.07%;合并血脂异常者25例,血脂控制达标率为72.00%。生活质量较月坛社区冠心病患者总体为高。结论老年冠心病患者接受PCI术后回到社区,其中约有70%在社区中接受全科医生的连续性随访与规范化管理,但规律服药率及合并症控制达标率仍有待进一步提高。

Objective To make an inquiry and survey of the continuous health management carried out by community general practitioners to the senile coronary heart disease（CHD） patients who were treated with PCI and currently live in Yuetan residential community,Beijing.Based on the survey,it was expected that further experience to be summed up to help raise the level of the relevant community health management.Methods From May 2008 to December 2009,in Yuetan residential community of Beijing,62 patients were selected among the CHD patients who were≥60 years old and accepted PCI at least 6 months before to be the objects of this research.Questionnaire and case retrospective survey were adopted in this research.Data including patients′ basic information,follow-up treatment at local community health centre,medicine application,control of relevant complication etc,were collected through questionnaire designed by researchers.Data obtained then were sorted out and analyzed while patients′ life quality index was evaluated with Table SF-36.Results It was found that among the 62 senile CHD patients treated with PCI,56.45% of them went to seek medical advice at community clinic once per month,69.35% of them went to see community general practitioners once every 1~3 months.In the past 1 year,18（29.03%） objects were treated by general practitioners or specialists through dual referral system for totally 21 times.After PCI,regular prescription rate of the senile CHD patients tended to be significantly high within the first 6 months,but lowered in the follow-up treatment 1 year later,especially for statins.Among the 53 objects combined with hypertension,83.02% of them,blood pressure was well controlled within the normal standard.Among the 29 objects combined with diabetes,62.07% of them became normoglycemia.Among the 25 objects combined with hyperlipoidemia,72.00% of them became ortholiposis.Their index of life quality showed to be significantly higher than the average level of the CHD patients in Yuetan residential community.Conclusion After receiving PCI,approximately 70% of the senile post-PCI CHD patients move back to their residential community and receive continuous follow-up treatment and standard management offered by general practitioners of local community health service centre,but regular prescription and the control of relevant complication however,still remain to be further improved.