慢性心力衰竭患者医院与社区联合规范化管理的效果评价

Evaluation of hospital and community management in patients with chronic heart failure

目的：探讨医院与社区联合对慢性心力衰竭（CHF）患者进行规范化管理的效果和管理模式的可行性。方法：以上海市普陀区下辖的10个社区作为研究基地，计划入选2009年9月一2011年3月于上海市普陀区中心医院就诊的NYHA心功能分级Ⅱ～Ⅳ级的CHF患者120例，以社区为基本单元，采用随机分组方法，将其分为干预组（共5个社区，59例患者）和普通随访组（共5个社区，57例患者）。干预组由中心医院对社区医生进行规范化心衰诊疗培训，由社区医生对患者进行管理，同时由区中心医院定期举办心衰（HF）知识讲座和HF自我管理教育；普通随访组进行常规门诊随访。观察两组患者18个月后HF知晓率、规范化药物使用率、日常生活管理、心功能改善情况、心脏事件、再次住院率、平均住院天数有无显著差异；观察干预组干预前后HF知晓率、规范化药物使用率、日常生活管理和心功能情况有无显著差异。结果：两组患者的基线特征无统计学差异。接受规范化管理后，干预组与普通随访组比较：HF知晓率（100％郴．81％，P〈0．05）、规范化服药率[利尿剂（92％粥．54％，P〈0．05）、13受体阻滞剂（95％螂．58％，P〈0．05）、血管紧张素转换酶抑制剂（ACEI）／血管紧张素受体阻滞剂（ARB）（93％ vs．58％，P〈0．05）]、自我日常生活管理率[限盐、控制饮食（92％傩．25％，P〈0．05）、戒烟（52％弧25％，P〈0．05）、适量运动（51％掷．18％，P〈0．05）、监测血压心率（93％＇／35．23％，P〈0．05）]、左室射血分数（LVEF）[（47±4）％傩．（42±6）％，P〈0．05]、NYHA心功能I～Ⅱ级（68％vs．49％，P〈0．05）]、再次住院率（34％郴．54％，P〈0．05）、住院天数[（8．3±2．2）dus．（9．2±2．1）d，P〈0．05]均有显著差异，两组心脏事件发生率（8％．9％）无统计学差异；干预组试验后均优于试验前。结论：医院与社区相结合的CHF规范化防治的管理模式是一种有效可行的方式，可以提高患者对疾病的认知率，规范化服药率和自我管理能力，降低再次住院率，缩短住院天数，从而获得较好的社会经济效益。

AIM： To evaluate the efficacy and feasibility of hospital and community management in patients with chronic heart failure. METHODS： Ten communities in Putuo District were included in this study and a total of 120 patients with heart failure （New York Heart Function II-IV） visiting Putuo District Center Hospital from September 2009 to March 2011 were investigated. The patients were divided into two groups ： management group （ n = 59 ） and control group （ n = 57 ）. In the management group, the community hospital doctors were trained according to the standardized guidelines for the management of heart failure. Patients received self-care education by center hospital doctors, whereas patients in the control group were treated without special training. The two groups were observed in the aspects of Datients＇ knowledge about heart failure, standardized medication, level of self-care in daily life, major adverse cardiac events, and hospitalization time. RESULTS： No significant differences were observed between groups at baseline. After an 18-month follow-up, the rate of patients＇ knowledge about heart failure （100% vs. 81%, P 〈0. 05）, rate of standardized medication [ diuretics （92% vs. 54%, P 〈 0. 05）, beta-blockers （95% vs. 58%, P 〈0. 05）, ACEI/ARB （93% vs. 58%, P 〈0.05） ] and rate of self-care in daily life [ salt restriction （92% vs. 25 %, P 〈 O. 05 ）, stopping smoking （52% vs. 25%, P 〈0. 05）, physical exercise （51% vs. 18%, P 〈 0.05 ）, blood pressure and heart rate monitoring （93% vs. 23%, P 〈0. 05） ], and days of hospitalization [ （8.3 ±2.2） days vs. （9.2 ±2. 1 ） days, P 〈 0. 05 ] in the management group were higher than those in the control group. The iate of MACE was lower （8% vs. 9% , P 〉0. 05） in the management group than in the control group. CONCLUSION： Hospital and community management in patients with chronic heart failure is feasible and effective.