大型医疗机构指导院外规范化管理对冠心病患者的效果分析

目的：探索大型医疗机构指导院外规范化管理，在降低冠心病患者死亡率及再入院率等一级终点事件以及提高依从性方面的意义。方法15个社区冠心病患者共2000例，意向治疗1642例，对其中10个社区的卫生服务机构人员进行培训并建立和实施患者管理计划，列为管理组，其余5个社区不进行医师培训和对患者管理，列为非管理组。随访期为23个月。结果管理组患者全因死亡、心源性死亡、心血管事件再入院等一级终点事件发生率明显低于非管理组，分别下降约37%、8%、56%；管理组患者心功能控制率明显高于非管理组，除拜阿司匹林外，两组患者其他冠心病治疗基础药物的使用依从性均较好。结论通过大型医疗机构指导院外规范化管理，能降低冠心病患者一级终点事件发生率，改善心功能，提高生活质量。

Objective To explore its meaning of reducing mortality and readmission rate an endpoint events and improving the compliance aspects through community’s regulated management by large scaled medical institute . Methods A total of 2,000 cases of coronary heart disease in 15 groups were enrolled,intention to treat population reached 1,642 cases,of which 10 communities on health services personnel training and establish and implement patient management plans,as a management group, and the remaining five communities without physician training and patients management,as a non-management group.The follow-up period was 23 months. Results Management of all-cause mortality in patients,cardiac death,cardiovascular events,such as a re-admission endpoint events were significantly lower than non-management group,were down about 37%,8%,56%;management control of cardiac function in patients rate was significantly higher than non-management group,in addition to aspirin,the other two groups of patients with coronary heart disease treatment based drug use compliance are good. Conclusion Through community’s regulated management instructed by larged scaled medical institution,the incidence of endpoint events of patients has a significant reduction,the heart function and quality of life were improved.