医院-社区-家庭联动管理方案的制订及其在冠心病患者二级预防中的应用研究

Application of linkage management model in the secondary prevention of coronary heart disease

目的探讨医院-社区-家庭联动管理对冠心病患者的二级预防的效果。方法采用类实验性研究方法,将武汉市2个大型社区182例冠心病患者分为实验组(95例)和对照组(87例),实验组接受医院-社区-家庭联动管理;对照组接受常规护理、出院指导和不定期随访,观察两组出院后1个月和1年后患者治疗依从性及1年后再入院率、主要心血管不良事件及并发症发生率、冠心病危险因素控制率和患者生活质量的变化。结果两组1个月后遵医行为差异无统计学意义(P>0.05);1年后实验组遵医行为高于对照组,1年后冠心病复发再入院率、主要心血管不良事件及并发症发生率低于对照组,冠心病危险因素控制率和患者生活质量优于对照组,差异有统计学意义(P<0.01)。结论医院-社区-家庭联动管理能够改善冠心病患者二级预防的效果,提高患者的治疗依从性,降低冠心病的复发率,减少心血管不良事件及并发症的发生,提高患者的生活质量。

Objective To explore the effects of linkage management model on the secondary prevention of coronary heart disease. Methods A quasi-experimental study design was adopted. Totally 182 coronary heart disease patients from two large communities in Wuhan were included. Patients were divided into the control group （87 cases） and the experimental group （95 cases）. The control group received routine treatment,discharge guidance and irregular follow-up. On the basis of management for control group,the experimental group received the hospital- community-family trinity linkage management mode. We observed the compliance behavior of the two groups 1 month and 1 year after discharge,and the rate of relapse re-admission 1 year after discharge,main cardiovascular events and the rate of complications,the control rate of coronary heart disease risk factors and the changes of quality of life of patients. Results There was no significant difference in the compliance between two groups at the time of 1 month（P〉0.05）. Compared with the control group,the experimental group showed significantly higher compliance one year later,including correct taking medicine,reasonable diet,quitting smoking and limiting alcohol, keep exercising,emotional control,self-monitoring and regular reexamination（P〈0.05 or 0.01）. Correspondingly, 1 year later,the rate of re-admission,the incidence of major cardiovascular events and complications of coronary heart disease were significantly lower in the experimental group than those in the control group（P〈0.01）. Importantly,the control rate of coronary heart disease risk factors and quality of life of patients were significantly better in the experimental group than the control group（P〈0.01）. Conclusion Application of the hospital-community-family trinity linkage management model is beneficial to improve patients＇ treatment compliance and reduce the recurrencerate,cardiovascular adverse events and complications. This model can improve patients＇ quality of life.