综合干预对提高社区医生心血管疾病危险因素管理水平的效果研究

Study on the effect of comprehensive intervention in the management of cardiovascular disease risk factors for general practitioners

目的评价综合干预措施对提高社区医生心血管疾病及危险因素管理水平的效果。方法采取简化临床路径、电子临床决策支持系统、关键绩效考核指标（KPIs）和反馈机制及与质量相关的激励制度，对北京市朝阳区35家社区卫生服务中心进行干预。在干预前（2014年1-6月）、第1周期干预（2014年8-10月）、第2周期干预（2014年12月-2015年2月）后，分别根据社区卫生服务中心门诊就诊病历号按随机数表法随机抽取病例2100、2089和2052份，提取病历中就诊记录，评价干预前后KPIs变化趋势。结果经2个周期的干预后与干预前比较，社区医生对患者是否有高血压（99．9％比70．5％，X2=708．9）、糖尿病（99．6％比41．5％，X2=1691．1）、高脂血症（99．5％比37．0％，X^2=1854．9）、冠状动脉粥样硬化性心脏病（冠心病）（99．6％比54．3％，X^2=1190．9）和脑卒中病史（99．4％比39．7％，X^2=1736．2）记录有显著提高（P〈0．001）。其他危险因素包括吸烟记录（70．0％比0．1％，X^2=2179．2）、身高体重记录（81．4％比72．2％，X^2=50．3），以及健康宣教，包括建议体力活动记录（75．0％比68．2％，X2=24．0）、建议控制体重（75．4％比16．2％，X^2=1467．1）记录也有显著提高（P〈0．001）。高血压患者不用降压药物的比例在干预前为31．6％，干预后第1个周期降低到20．2％，在干预后的第2个周期为25．8％；冠心病、脑卒中、糖尿病患者服用阿司匹林、B受体阻滞剂、血管紧张素转换酶抑制剂（AGED或血管紧张素受体拮抗剂（ARB）类药物、他汀类药物的比例均有升高（P〈0．05），冠心病患者B受体阻滞剂应用率在干预前为20．2％，第2周期干预后上升至27．9％，糖尿病患者他汀类药物应用率在干预前为32．1％，第2周期干预后上升至40．9％。结论通过采用简化临床路径、电子临床决策支持系统、KPIs反馈机制及与质量相关的激励制度等干预措施能够提高社区医生管理心血管疾病危险因素水平，是有效管理慢病的方法。

Objective To evaluate the effect of interventions for improving the management of cardiovascular risk factors in general practitioners. Methods Interventions were conducted in thirty-five community health service centers in Chaoyang District of Beijing using simplified clinical pathways, clinieal decision support systems, service quality evaluation index and feedback mechanism, and quality-related motivation system. The research was divided into three periods, which were indicated as before the interventions （2014.1-6）, after the first intervention （2014.8- 10）, and after the second intervention （2014.12-2015.2）, according to the community service center outpatient clinic, the computer randomly selected 2 100, 2 089 and 2 052 subjects. With the method of retrospective case review, historical case records of each selected case were extracted, and the changes in KPIs before and after interventions were evaluated. Results After two cycles of intervention, compared with before the interventions, the capability of general practitioners to record hypertension （99.9% vs. 70.5%, X^2=708.9）, diabetes （99.6% vs. 41.5%, X^2= 1691.1）, hyperlipidemia （99.5% vs. 37.0%, X^2=1854.9）, coronary atherosclerotic heart disease （CHD） （99.6% vs. 54.3%, X2=1190.9）, and cerebral hemorrhagic stroke （99.4% vs. 39.7%, X^2=1736.2） had significantly increased （P〈0.001）. Records of other risk factors, for instance, height and weight （81.4% vs. 72.2%, X^2= 50.3）, smoking （70.0% vs. 0.1%, X2=2 179.2）, and health education including recommended physical activity （75.0% vs. 68.2%, X^2=24.0） and weight control （75.4% vs. 16.2%, X^2=1 467.1） significantly increased （P〈 0.001）. The proportion of patients with hypertension who did not use antihypertensive drugs was 31.6% before the intervention; in the first period of intervention, it reduced to 20.2%, and in the second period after the intervention it was 25.8%. Cases of CHD, stroke, diabetes, patients taking aspirin, beta blockers, angiotensin converting enzyme inhibitors （ACEI） or angiotensin receptor blockers （ARB） in proportion to the class of drugs, and statins increased （P〈0.05）; the coronary atherosclerosis heart disease patients with beta-blockers utility ratio was 20.2% before the intervention, and in the second cycle it was up to 27.9% after the intervention; for patients with diabetes statins utility ratio was 32.1% before the intervention, and in the second cycle it was up to 40.9% after the intervention. Conclusion Adoption and implementation of a series of interventions such as simplified clinical pathways, clinical decision support systems, service quality evaluation index and feedback mechanism, and quality-related motivation system will be beneficial to improve the capability of general practitioners to manage the cardiovascular disease risk factors, which are implied to be effective methods for managing chronic diseases.