基于互联网实现慢性心衰患者自我管理的实践与效果分析

Practice and Effect Analysis of Self-management of Patients with Chronic Heart Failure Based on Internet

目的探讨基于互联网的专科-全科医师团队引导慢性心力衰竭患者自我管理及效果分析。方法选取2020年4-5月在某三甲医院心脏中心治疗的50例慢性心力衰竭患者作为研究对象,通过组建心衰管理团队、网上医院、随访、微信沟通等方式,采行线上线下专科指导照护、医院社区双向转诊、全科跟进康复管理等措施对慢性心力衰竭患者进行管理。6个月后评价慢性心力衰竭患者的自我管理状况和再入院率。结果比较干预前后慢性心力衰竭患者自我管理评分及再入院率,差异有统计学意义(p<0.05);与同类慢性心衰管理项目相比(单样本t检验),差异有统计学意义(t=2.55,p=0.014)。结论基于互联网的专科-全科医师团队能提高慢性心力衰竭患者自我管理水平,降低再入院率。

Objective To explore how an Internet-based specialist-general practitioner team guides the self-management and effect analysis of patients with chronic heart failure.Methods 50 patients with chronic heart failure treated in the heart center of a grade-A tertiary hospital from April to May of 2020 were selected as the research objects.Through the establishment of a heart failure management team,online hospital,follow-up,WeChat communication,etc.,many measures were taken to manage patients with chronic heart failure such as online and offline care under specialist guidance,hospital and community two-way referral,general practice follow-up rehabilitation management.Six months later,the self-management status and readmission rate of patients with chronic heart failure were evaluated.Results The self-management scores and readmission rates of patients with chronic heart failure before and after the intervention were compared,and the difference was statistically significant(p<0.05).Being compared with similar chronic heart failure management items(single-sample t-test),the difference was statistically significant(t=2.55 p=0.014).Conclusion The Internet-based specialist-general practitioner team can improve the self-management level of patients with chronic heart failure and reduce the readmission rate.