社区管理-自我管理对老年慢性心力衰竭患者依从性及预后的干预效果研究

Effects of Community-management Combined with Self-management on the Compliance and Prognosis of Elderly Patients with Chronic Heart Failure

目的评估社区管理-自我管理相结合的疾病管理模式对出院老年慢性心力衰竭患者依从性及预后的干预效果。方法连续选取2014—2015年于秦皇岛市第一医院全科医疗科出院的慢性心力衰竭患者200例为研究对象,根据随机数字表将患者分为干预组(100例)和对照组(100例)。干预组采取社区管理-自我管理干预,由社区卫生服务中心进行定期的门诊或上门随访,提供药物治疗调整、患者和家庭成员咨询等服务;出院前患者接受当面的健康教育,出院后每月1次上门随访时对患者进行自我管理培训。对照组患者仅出院时接受常规出院指导。12个月后进行1次临床随访,了解患者心血管事件的发生、药物应用情况,采用欧洲心力衰竭自我护理行为量表(EHFSc BS)评估自我护理能力。结果随访期间,对照组心血管事件发生率为74.0%(74/100),中位无事件生存时间180 d;干预组心血管事件发生率为51.0%(51/100),中位无事件生存时间356 d。Log-rank检验显示,干预组预后优于对照组(χ2=22.961,P<0.001)。干预组β-受体阻滞剂使用率[89.6%(86/96)]高于对照组[78.4%(69/88),P<0.05],干预组EHFSc BS总分为(28.5±4.4)分,低于对照组的(36.0±5.1)分(P<0.001)。多因素Logistic回归分析显示,纽约心功能分级(NYHA分级)高[OR=2.259,95%CI(1.326,3.851)]、伴发糖尿病[OR=3.374,95%CI(1.388,8.203),P=0.007]是发生心血管事件的促进因素,社区管理-自我管理[OR=0.240,95%CI(0.114,0.505)]是发生心血管事件的保护因素(P<0.05)。结论社区管理-自我管理相结合的疾病管理模式可显著改善老年慢性心力衰竭患者的治疗依从性,提高自我护理能力,降低心血管事件的发生风险,改善预后。

Objective To evaluate the intervention effect of community-management with self-management on the treatment compliance and prognosis of discharged elderly patients with chronic heart failure(CHF).Methods 200 consecutive elderly patients with CHF discharged from Department of General Medicine,First Hospital of Qinhuangdao from 2014 to 2015 were enrolled and divided into the intervention group(100 cases)and control group(100 cases)by the random number table.Both community-management(services such as adjusting the medication and answering the questions of the patients and their family members during regular outpatient or home follow-ups provided by the local community health center)and selfmanagement based on face-to-face health education before the discharge and self-management training offered during the home follow-up once a month by the local community health center were given to the intervention group.In contrast,the control group only received the conventional discharge guidance.The clinical follow-up was conducted 12 months later to investigate the incidence of cardiovascular events,use of drugs,as well as self-management level〔assessed by European Heart Failure Self-care Behavior Scale(EHFScBS)〕.Results The follow-up found that compared with the control group,the intervention group demonstrated lower incidence of cardiovascular events〔51.0%(51/100)vs 74.0%(74/100)〕,longer median event-free survival(356 d vs 180 d).Moreover,the intervention group presented a better prognosis(χ2=22.961,P<0.001)revealed by Log-rank test and higher rate of beta-blocker use〔89.6%(86/96)vs 78.4%(69/88),P<0.05〕.In addition,lower total EHFScBS score was found in the intervention group〔(28.5±4.4)vs(36.0±5.1),P<0.001〕.Multivariate Logistic regression analysis demonstrated that high NYHA class〔OR=2.259,95%CI(1.326,3.851)〕and diabetes〔OR=3.374,95%CI(1.388,8.203)〕were risk factors for cardiovascular events,while community-management with self-management〔OR=0.240,95%CI(0.114,0.505)〕was a protective factor for cardiovascular events(P<0.05).Conclusion Community-management with self-management can significantly enhance the treatment compliance and self-care ability,reduce the risk of cardiovascular events and improve prognosis among elderly patients with CHF.