医院-社区一体化冠心病管理模式干预效果评价

Evaluation of the effect of comprehensive intervention on patients with coronary heart disease under hospital-community health integrated management mode

目的:探讨医院-社区一体化冠心病管理模式干预效果。方法:选取苏州市盛泽镇361例冠心病患者,进行为期1.5年医院-社区一体化冠心病综合干预,包括健康教育、行为干预、心理干预及药物干预,并进行效果评价。结果:与干预前比较,干预后冠心病危险因素知晓度、健康行为形成率、规律服药率明显提高(P<0.01),血压、体质指数明显降低(P<0.01),血脂、血糖水平明显改善(P<0.05)。结论:医院-社区一体化冠心病管理模式干预效果显著,具有重要示范和推广意义。

Objective：To explore the effect of comprehensive intervention to patients with coronary heart disease under hospital-community health integrated management mode. Method：Comprehensive intervention on 361 patients with coronary heart disease from Shengze Jiangsu was carried out for 1.5 years,which included health education and behavior,psychological and drug intervention. Result：Under the integrated management mode：the rate of coronary risk factors awareness,healthy-behavior formation and regularly taking medicine were significant increased（P=0.000）;the index of blood pressure and weight were significantly decreased（P0.01）;the level of blood glucose and lipid profile were significantly improved（P0.05）. Conclusion：The effect of establishing comprehensive intervention by hospital-community health integrated management mode to coronary heart disease is meaningful,which should be promoted.