全程动态疾病管理模式对慢性心力衰竭患者预后的影响

Influence of dynamic disease management model to the prognosis of patients with chronic heart failure

目的研究对于慢性心力衰竭患者实施医院与社区联合全程动态疾病管理模式对患者预后的应用效果。方法我院于2015年9月-2016年9月收治的慢性心理衰竭患者提供常规疾病治疗及院内护理措施,于2015年10月-2016年10月由医院联合社区为患者提供联合疾病管理模式,同时选取上述时间段内患者各78例,包括对照组与干预组,观察两组患者生存质量评价及对护理服务质量评分,总结患者再次入院治疗情况。结果对照组患者症状表现、活动限制、社会活动度及情绪变化等指标评分均较低,干预组上述评分均高于对照组,P〈0.05。对照组患者在健康指导、疾病知识宣传、用药与康复护理及定期随访等指标评分均低于干预组,P〈0.05。对照组78例患者中,二次住院接受治疗为27例（34.62%）,干预组为6例（7.69%）,P〈0.05。结论对于慢性心力衰竭患者提供全程动态疾病管理模式服务,大部分患者生活质量评价较好,且患者对于护理服务质量评分较高,患者再次入院接受治疗情况较少。

Objective To study application effect of hospital and community integrated dynamic disease management model to the prognosis of patients with chronic heart failure. Methods Patients with chronic heart failure cured in our hsopital from September 2015 to September 2016 were given routine treatment and nursing measures. Joint disease management model was given on the patients from October 2015 to October 2016 from hospital and community. Meanwhile, 78 patients were selected into control group in the above period, and 78 patients were selected into intervention group. Evaluation of quality of life and quality of nursing service of the two groups were observed. Re admission treatment of the two groups were summaried. Results In the control group, the scores of symptoms, activities, social activities and emotional changes were lower. The above scores of the intervention group were higher than those of the control group, P〈0.05. The health guidance, knowledge of disease knowledge, medication and rehabilitation care and regular follow-up of patients in the control group were lower than those in the intervention group, P〈0.05. Among 78 patients in control group, there were 27 cases second visit hospital for treatment（34.62%）, and the intervention group with 6 cases（7.69%）, P〈0.05. Conclusion For patients with chronic heart failure, dynamic disease management model can improve the quality of life of most patients and nursing quality score. The situation of once again admitted to the hospital for treatment becomes less.