慢性心力衰竭社区疾病管理模式探索

Community-based Disease Management Model for Chronic Heart Failure

目的了解社区慢性心力衰竭人群现状特点,依据人群特点制定慢性心力衰竭社区管理方法,同时探讨社区管理能否使患者获益,以期为慢性心力衰竭的综合防治提供新思路。方法选取2012年3—4月长沙市浏府街社区自愿参与调查的慢性心力衰竭患者288名,采用自行设计的问卷调查该社区心力衰竭人群特点;另选取2012年5月—2013年5月该社区自愿参加慢性心力衰竭社区疾病管理的患者200名,采用自行设计的系统的慢性心力衰竭社区疾病管理方法,对其药物治疗、健康教育、生活方式、自我管理等进行干预,观察干预前后患者基本指标控制情况、心力衰竭常规药物使用率、心力衰竭知识知晓率、自我管理情况、明尼苏达生活质量(MNLF)评分、再住院次数、心血管事件发生率等。结果 (1)共发放调查问卷288份,回收279份,回收率为96.88%,有效问卷274份,有效率为98.21%,患者平均年龄为(68.7±10.6)岁;MNLF评分为(22.13±14.64)分;低盐低脂饮食率68.61%(188/274);定期测量血压率41.97%(115/274);高血压控制率为35.40%(97/274);主动随诊率为25.18%(69/274);主动健康教育率为8.03%(22/274)。(2)干预后,患者心率控制率、血压控制率均高于干预前(P<0.05);干预前后患者血糖控制率比较,差异无统计学意义(P>0.05)。干预前,患者血管紧张素转换酶抑制剂(ACEI)/血管紧张素Ⅱ受体拮抗剂(ARB)使用率、β-受体阻滞剂使用率、慢性心力衰竭知识知晓率、低盐低脂饮食率、戒烟率、定期测量血压率、定期测量脉搏率均低于干预后(P<0.05)。通过绿色通道就诊者31例,双向转诊者5例,家庭随访者5例。结论慢性心力衰竭社区疾病管理能使患者获益,是一种值得提倡的管理模式。

Objective To understand the characteristics of people with chronic heart failure in community,based on which to make the suitable community management of the disease,next to discuss whether patients with chronic heart failure can benefit from the community management or not,so as to provides a new way for comprehensive prevention of chronic heart failure. Methods （1） Self-designed questionnaire was used to investigate 288 patients with chronic heart failure in Liufu Street community of Changsha from March to April in 2012 who volunteered to take part in the community management about the characteristics of heart failure population. （2） Self-designed systematic management methods of chronic heart failure disease was used to interfere another 200 patients in the community drug treatment from May 2012 to May 2013,health education,lifestyle,self-management,etc. Patients＇ basic indexes controlling situation,usage rate of heart failure conventional drugs,awareness rate of heart failure knowledge,self-management,MNLF scores,frequency of hospitalization and incidence of cardiovascular events were observed before and after the intervention. Results （1）288 questionnaire were sent out,receiving 279 questionnaires with a recovering rate of 96. 88% and 274 valid questionnaires with an effective rate of 98. 21%. The average age of the patients was（68. 7 ± 10. 6）;MNLF score was（22. 13 ± 14. 64）;68. 61%（188/274）of the patients had low salt and low fat diets;41. 97%（115/274）measured their blood pressure on a regular basis;the control rate of blood pressure was 35. 40%（97/274）;the active follow-up rate was 25. 18%（69/274）and the active accepting health education was 8. 03%（22/274）.（2）After intervention,blood pressure control rate and heart rate control rate were higher than before（P﹤0. 05）. The difference of blood sugar control rate before and after intervention was not significant（P﹥0. 05）. The usage rate of ACEI/ARB andβblockers,the awareness rate of heart failure knowledge,the percentage of patients who had low salt and low fat diets,measured blood pressure and blood rate regularly were all lower before intervention than after intervention （ P﹤0. 05 ） . 31 people visited hospitals through＆quot; the green channel＆quot;,5 individuals through two-way referral and 5 through families follow-up. Conclusion Chronic heart failure disease management model in community can bring benefit to patients and is worthy of advocating.