医院与社区协同健康管理模式对冠状动脉介入术后老年冠心病患者的影响

Community and hospital joint management for elderly patients after percutaneous coronaryintervention

经皮冠状动脉介入治疗术（PCI）后老年冠心病患者172例，按照所在社区分为对照组（78例）和观察组（94例）。对照组出院后转社区医疗组织管理，医院不再提供后续健康干预治疗；观察组出院后由医院协同社区共同健康管理1年，比较两组患者遵医服药率、再住院率、平均再住院天数、平均再住院费用及心脏事件发生率，及生活质量综合评定问卷（GQOLI-74）、焦虑自评量表（SAS）、抑郁自评量表（SDS）评分。结果显示，观察组患者再住院例数、平均再住院天数、平均再住院费用及SAS、SDS评分均明显降低（P〈0．01或〈0．05），遵医服药率及躯体健康度、心理健康度、社会功能维系度方面好于对照组（P〈0．05），但在心脏事件发生率及物质生活维系度改善方面差异则无统计学意义（P〉0．05）。提示，医院、社区协同健康管理模式是老年PCI术后患者降低再住院率、减轻医疗负担、提高生存质量切实有效的管理措施。

Among 172 patients with coronary artery disease （CAD）, 94 received community and hospital joint management （joint group） after percutaneous coronary intervention （PCI） for I year and 78 received community-based health education only （control group） after PCI. The compliance of medication, readmission rate, times of hospitalization, medical costs, major adverse cardiac events （MACE）, and general quality of life inventory （CQOLI-74）, self-rating anxiety scale （SAS） and self-rating depression scale （SDS） scores were compared between two groups. The rate of readmission, times of hospitalization, medical costs, the sores of SAS and SDS in joint group were lower than those in control group（P 〈0. 01 or 0. 05） . The compliance of medication, body health dimension, psychological health dimension and social function dimension in joint group were better than those in control group, but there were no differences in material life dimension and the MACE rate between two groups （ P 〉 0.05 ）. Community and hospital joint management can reduce the readmission rate and medical burden, and improve quality of Rife for elderly CAD patients after PCI.