社区卫生服务中心管理窗口模式管理心房颤动患者效果分析

Management window for patients with atrial fibrillation in community health center

建立心房颤动（房颤）管理窗口，筛查在本社区卫生服务中心就诊的房颤患者并纳入管理，采用综合治疗管理方案和流程对患者进行治疗管理和随访。结果有效管理房颤患者105例（97．2％），平均管理随访10．6个月；CHADS：评分≥2分78例，其中服用华法林11例，占14．1％；26例阵发性房颤无一例转变为持续性房颤。与管理前比较，房颤患者管理后服用阿司匹林和华法林比率均提高（均P〈0．05），口服华法林患者INR达标率提高（P〈0．05）；纳入管理的患者均接受综合诊疗方案、规范治疗和健康教育，较管理前明显好转（均P〈0．05）；患者对疾病认识、治疗的依从性和满意度均明显提高（均P〈0．05）。提示社区卫生服务中心以房颤管理窗口模式对房颤患者进行治疗管理，对减少房颤复发，提高华法林使用率，提高患者合理治疗的依从性是可行有效的。

A management window model for patients with atrial fibrillation （AF） was established in Tilanqiao Community Health Service Center cooperated with tertiary hospitals. Patients were screened and treated in the community health service center, and a comprehensive management plan was conducted and patients were followed-up. A total of 105 patients with atrial fibrillation （97. 2% ） were effectively managed with an average follow-up of 10. 6 months. The CHADS2 score /〉 2 in 78 cases, including 11 cases with administration of warfarin （ 14. 1% ） and 26 cases with paroxysmal AF without transition to persistent atrial fibrillation. Compared to the data before management, the rate of taking aspirin and warfarin in managed patients was increased （ all P 〈 0. 05 ）, the international normalized ratio （ INR ） of patients receiving warfarin was improved （ P 〈 0. 05 ） ; the ratio of receiving comprehensive treatment program, standardized treatment and health education were significantly increased （ P 〈 0. 05 ） ; the awareness of the disease, treatment compliance and satisfaction of patients were improved significantly （ all P 〈 0. 05 ）. The results suggest that the management widow model is feasible and effective for management of patients with atrial fibrillation in community health service centers.