基于临床路径理论动脉粥样硬化性心血管疾病基层管理路径的初步研究

A preliminary study on the management pathway of atherosclerotic cardiovascular diseases in primary care based on clinical pathway theories

目的 通过试点研究验证初步设计的动脉粥样硬化性心血管疾病（ASCVD）基层管理路径的可行性和有效性.方法 以沈阳市长白社区卫生服务中心122例签约全科医生团队服务的ASCVD高危慢病共病患者为研究对象,采用白身对照临床试验的方法,按照预先设计的ASCVD基层管理路径采用创新性研制的“协同式”基层管理措施实施规范化基层管理,评价干预6个月前后的管理效果.结果 干预6个月后,患者失访率为7.4％ （9/122）,1 13例研究对象完成问卷调查,问卷均合格有效.干预后患者积极度总体水平较干预前提高,差异具有统计学意义（t=5.809,P＜0.05）.各维度得分：相信积极主动的角色很重要（t =4.546,P ＜0.05）、有采取行动的信心与知识（t=4.684,P＜0.05）、实际采取行动（t=5.332,P＜0.05）以及压力下仍能坚持（t=7.785,P＜0.05）也较干预前明显提高,差异有统计学意义.患者生命质量总分（t=2.086,P＜0.05）、心理健康总分（t=1.980,P＜0.05）、生理功能（t=2.420,P＜0.05）、活力（t=3.077,P＜0.05）、精神健康（t=2.992,P＜0.05）较干预前显著提高,其差异有统计学意义.患者积极度和生命质量明显相关（r=0.320,P＜0.05）.患者血压、糖化血红蛋白、血脂水平均较干预前有所下降,其中舒张压干预前后间差异具有统计学意义（t=2.015,P＜0.05）.结论 ASCVD基层管理路径及“协同式”干预措施在基层具有可行性和有效性,实施后可通过增强患者积极度改善患者生命质量,并在不同程度上改善了患者血压水平等临床结果.

Objective To evaluate the feasibility and effectiveness of the management pathway of atherosclerotic cardiovascular disease （ASCVD）.Methods One hundred and twenty two elderly patients with more than one ASCVD risk factors contracting general practice service in Changbai Community Health Center of Shenyang Municipality were enrolled.The management pathway of ASCVD was conducted with a integrated intervention model based on the self-control studv design.The effects were evaluated with Hihbard＇s Patient Activation Measure （PAM） after 6 months of intervention.Results After 6 months,9 participants dropped out of study （7.4%）.The questionnaire survey was conducted in 113 participants and the response rate was 100%.After intervention,the overall level of activation in participants was increased （t =5.809,P 〈 0.05）.The scores of four stages of activation were increased：believing the importance of active role（t =4.546,P 〈 0.05）,confidence and knowledge of taking action （t =4.684,P 〈 0.05）,taking action（t =5.332,P 〈0.05）,staying the course under stress （t =7.785,P 〈0.05）.The total scores （t =2.086,P 〈 0.05） and the scores of mental component summarv （t =1.980,P 〈 0.05）,physical function （t =2.420,P 〈 0.05）,vitality （t =3.077,P 〈 0.05）,mental health （t =2.992,P 〈0.05） in SF-36 were increased.The activation of patients was significantly correlated with the quality of life （r =0.320,P 〈 0.05）.After intervention,the blood pressure,HbA1c,blood lipid levels trended to be decreased,and the diastolic blood pressure was significantly decreased after intervention （t =2.015,P 〈0.05）.Conclusion The ASCVD management pathway and ＂integrated intervention＂ model in primary care is feasible and effective.After the implementation,the activation of patients is increased,the quality of life and clinical outcomes are improved in different degrees.