医联体模式跨理论改变模型慢性传染性疾病健康管理体系构建与评估

Construction and practice of health management system for patients with chronic infectious diseases based on trans-theoretical model of change from a regional medical consortium

目的构建及评价医联体模式下基于跨理论改变模型(TTM)的慢性传染性疾病患者健康管理体系及效果,为创新下沉管理提供参考。方法选取2018-10-01-2019-03-31东莞市长安镇艾滋病(AIDS)患者/人类免疫缺陷病毒(HIV)感染者(47例)、结核病(49例)及麻风病(1例)共97例慢性传染性疾病患者为研究对象,分为对照组(48例)和观察组(49例),均随访6个月。对照组行常规管理,观察组由医联体内东莞市长安医院、东莞市长安镇疾病预防控制中心和东莞市长安镇社区卫生服务中心工作人员组成团队行TTM健康管理。随访结束后对2组患者治疗依从性、生活质量及满意度3个方面进行评估和比较。结果干预6个月后,观察组处于准备阶段和行动阶段的患者占73.47%,高于对照组的27.08%,z=-5.185,P<0.001。干预6个月后,观察组饮食依从性得分为(8.73±0.17)分,高于对照组的(6.44±0.30)分,t=-5.356,P<0.001;运动依从性得分为(7.78±0.22)分,高于对照组的(6.17±0.29)分,t=-4.392,P<0.001;用药依从性得分为(8.24±0.14)分,高于对照组的(5.33±0.17)分,t=-7.892,P<0.001;预防措施依从性得分为(6.88±0.16)分,高于对照组的(5.19±0.14)分,t=-6.492,P<0.001;复查依从性得分为(6.16±0.15)分,高于对照组的(4.54±0.18)分,t=-6.447,P<0.001。干预6个月后,社会功能得分为(14.33±0.32)分,高于对照组的(10.81±0.34)分,t=-5.889,P<0.001;角色功能得分为(10.16±0.33)分,高于对照组的(8.65±0.35)分,t=-3.085,P=0.002;躯体功能得分为(16.12±0.38)分,高于对照组的(13.73±0.41)分,t=-3.943,P<0.001;情绪功能得分为(16.55±0.41)分,高于对照组的(13.46±0.55)分,t=-4.148,P<0.001;认知功能得分为(16.73±0.36)分,高于对照组的(12.94±0.45)分,t=-5.432,P<0.001。观察组满意度方面高于对照组,χ^(2)=8.908,P=0.003。结论医联体模式下基于TTM的慢性传染性疾病患者健康管理体系能改变患者所处的行为意向阶段,有效提高治疗依从性、生活质量和满意度。

Objective This study aimed to construct and evaluate effectiveness of health management system for patients with chronic infectious diseases based on trans-theoretical model of change(TTM)from a regional medical consortium,and to provide practice reference for innovation management.Methods By convenient sampling,a total of 97 cases with chronic infectious diseases such as AIDS/HIV(47 cases),tuberculosis(49 cases)and leprosy(1 cases)from October 1,2018 to March 31,2019 in Chang’an Town were selected as research objects.Subjects were randomly divided into control group(48 cases)and observation group(49 cases)and all were followed up in 6 months.Control group received conventional management,and observation group TTM from team composed of staff who worked in Chang’an hospital of Dongguan City,Chang’an Town of Dongguan city center for disease control and prevention,community health services centre of Chang’an town from a regional medical consortium.The two groups were evaluated and compared on treatment compliance,quality of life and patients’satisfaction to management at the end of follow-up.Results After being intervened for6 months,patients in observation group who were in preparatory phase and action phase accounted for 73.47%,far higher than 27.08%of the control group.There were significant differences on distribution of change phases of health behavior between the two groups(z=-5.185,P<0.001).After 6 months,in observation group dietary compliance score was(8.73±0.17),higher than that in control group(6.44±0.30),t=-5.356,P<0.001.After 6 months,in observation group exercise compliance score was(7.78±0.22),higher than that in control group(6.17±0.29),t=-4.392,P<0.001.After 6 months,in observation group medication compliance score was(8.24±0.14),higher than that in control group(5.33±0.17),t=-7.892,P<0.001.After 6 months,in observation group precautionary measures compliance score was(6.88±0.16),higher than that in control group(5.19±0.14),t=-6.492,P<0.001.After 6 months,in observation group reexamination compliance score was(6.16±0.15),higher than that in control group(4.54±0.18),t=-6.447,P<0.001.After 6 months,in observation social function score was(14.33±0.32),higher than that in control group(10.81±0.34),t=-5.889,P<0.001.After 6 months,in observation role function score was(10.16±0.33),higher than that in control group(8.65±0.35),t=-3.085,P=0.002.After 6 months,in observation physical function score was(16.12±0.38),higher than that in control group(13.73±0.41),t=-3.943,P<0.001.After 6 months,in observation emotive function score was(16.55±0.41),higher than that in control group(13.46±0.55),t=-4.148,P<0.001.After 6 months,in observation cognitive function score was(16.73±0.36),higher than that in control group(12.94±0.45),t=-5.432,P<0.001.Satisfaction rate in observation group were obviously higher than in control group(χ^(2)=8.908,P=0.003).Conclusion Health management system for patients with chronic infectious diseases based on TTM from a regional medical consortium can effectively change their behavioral intention phase,improve treatment compliance,quality of life and satisfaction to management.