南京市社区主要慢性病患者自我管理项目实施效果评估

Effectiveness evaluation on chronic disease self-management program among patients with chronic disease in Nanjing community

目的评价南京社区主要慢性病自我管理项目的实施效果。方法 2015年4—6月,以街道(乡镇)为单位,组建自我管理小组49个。活动内容参考上海复旦大学借鉴美国斯坦福大学创建的慢性病患者自我管理项目(CDSMP)。分别在基线和活动后6个月进行2次调查。结果共登记患者608例,完成6次活动的患者562例,应答率92.4%。与活动前相比,活动6个月后患者3种自我管理行为(每周伸展/力量锻炼、耐力锻炼时间、与医生交流评分)、症状管理和疾病共性管理自我效能、5种健康指标(疲劳、疼痛、气短、健康担忧、社会活动/角色受限)、生理和心理总评分均显著提高;住院次数、住院天数、体重、臀围、收缩压、舒张压、空腹血糖、总胆固醇、甘油三酰分别减少了(0.04±0.43)次、(0.17±2.11)d、(0.25±0.07)kg、(0.79±0.80)cm、(3.20±0.62)mm Hg、(1.94±0.92)mm Hg、(0.40±1.50)mmol/L、(0.28±0.95)mmol/L、(0.13±0.73)mmol/L,差异均有统计学意义(P<0.01)。结论 CDSM0项目可改善患者自我管理行为、自我效能、健康状况、生活质量;减少住院次数和天数;降低血压、血糖、血脂,适合在南京社区推广。

Objective To evaluate the effectiveness for main chronic disease self-management program （CDSMP） in Nanjing community. Methods From April to June 2015, the volunteer patients with medical record that confirmed a di- agnosis of one chronic disease were recruited. A total of 49 self-management groups were established. Nanjing CDSMP was based on the blueprint of Shanghai CDSMP developed at Stanford University. Baseline and six-month later interviews were conducted respectively. Results A total of 608 participants were recruited and agreed to enter CDSMP. 562 participants completed the 6-session activities, with the respond rate being 92. 4%. Compared to baseline, 3 of seE-management behav- iors [ stretching or strengthening exercise （minutes/week）, aerobic exercise （minutes/week）, communication with medi- cal doctor], self-efficacy to managing symptoms and self-efficacy to managing disease in general, 5 of health status （fa- tigue, pain, shortness of breath, health distress and social/role activities limitation）, the scores of quality of life in physi- cal component summary and mental component summary were all higher after six months intervention. After 6 months inter- vention, the number of times in hospital stay and nights in the hospital, the value of body weight, hip circumference, sys- tolic blood pressure, diastolic blood pressure, fasting plasma glucose, total cholesterol and triglyceride were decreased by （0.04±0.43） times, （0.17＋2.11） d, （0.25±0.07） kg, （0.79±0.80） cm, （3.20±0.62） mmHg, （1.94± 0.92） mmHg, （0.40±1.50） mmol/L, （0.28 ±0.95） mmol/L, （0.13 ＋0.73） mmol/L, respectively, all the differences were statistically significant （all P values 〈 0. 01 ）. Conclusion CDSMP based on Chinese locally patients for Nanjing improved participants＇ health behavior, self-efficacy, health status and the quality of life, and reduced the num- ber of times and nights in hospital six months after the program. CDSMP could be applied effectively in Nanjing.