个性化家庭医生签约服务对动脉粥样硬化性心血管疾病高危人群危险因素的干预效果研究

Efficacy of personalized family doctor contract services on the risk factors of atherosclerotic cardiovascular disease in high-risk people

目的:探讨个性化家庭医生签约服务对动脉粥样硬化性心血管疾病(ASCVD)高危人群不同危险因素的防控效果。方法:匹配深圳市罗湖区10家社区健康服务中心(社康中心),整群随机分为干预组和对照组。2018年8月至2019年4月利用10年ASCVD发病风险预测模型(China-PAR),从就诊10家社康中心且China-PAR预测模型资料完整的签约居民中,筛选出分值≥10分的ASCVD高危人群,进行前瞻性干预研究。对照组接受一般的家庭医生签约服务,干预组在此基础上,充分了解和关注患者想法、关心和期望(ICE)等,制定个性化管理措施,干预2年后比较两组自身及组间ASCVD各项危险因素得分变化。结果:共入选571例患者,干预组288例,对照组283例,干预2年后,分别失访7例、18例,最终干预组281例和对照组265例纳入研究。基线时,干预组和对照组ASCVD得分[(13.33±3.54)比(13.09±3.54)分]差异无统计学意义(t=0.84,P=0.403),干预后两组评分均明显下降[(10.89±4.01),(11.62±4.11)分],且干预组下降更明显(均P<0.05)。各危险因素中,基线时,干预组HDL-C和舒张压低于对照组,其余因素两组差异无统计学意义。干预后两组总胆固醇、收缩压、舒张压水平显著下降,服用降压药物人数明显提升(P<0.001);干预组干预后吸烟人数、女性腰围、全组空腹血糖、糖尿病患者空腹血糖水平下降(P<0.05);对照组HDL-C降低(P=0.023)。干预后两组间比较,干预组服用降压药物比例更高,收缩压和舒张压更低(P<0.05)。干预后干预组HDL-C上升比例高于对照组,下降比例低于对照组,差异有统计学意义(χ2=6.65,P=0.036)。结论:家庭医生签约服务能够降低ASCVD风险值,个性化家庭医生签约服务可以在一定程度上进一步提升ASCVD危险因素防控效果,但效果不一致,一些需要更深层次管理的危险因素防控效果不显著,需进一步探索管理方式。

Objective To investigate the efficacy of personalized family doctor contract services on risk factors of atherosclerotic cardiovascular disease(ASCVD)in high-risk population.Methods Ten matched-community health centers of Shenzhen Luohu district were divided into intervention group and control group by cluster randomiztion.Subjects with high risks of ASCVD were screened out as intervention group from contracted residents who visited these centers and had complete data of the China-PAR model from August 2018 to April 2019.The control group received conventional general family doctor contract services.The individualized management were given to the intervention group after fully understanding patients′ideas,concerns,and expectations(ICE).After 2-year intervention,score changes of ASCVD risk factors within and between groups were compared.Results A total of 571 patients were enrolled,including 288 in the intervention group and 283 in the control group.After 2 years of intervention,7 and 18 were lost to follow-up in two groups,respectively.Finally,281 in the intervention group and 265 in the control group were included in the study.At baseline,there was no significant difference in ASCVD scores between the intervention group and the control group[(13.33±3.54)vs.(13.09±3.54)points;t=0.84,P=0.403],and the scores in both groups decreased significantly after the intervention[(10.89±4.01),(11.62±4.11)points],while the intervention group decreased more significantly(both P<0.05).Among the risk factors at baseline,HDL-C and diastolic blood pressure in the intervention group were lower than those in the control group,and there were no significant differences in other factors between the two groups.After the intervention,the levels of total cholesterol,systolic blood pressure and diastolic blood pressure in the two groups decreased significantly,and the number of people taking antihypertensive drugs increased significantly(P<0.001 and P<0.05);HDL-C decreased in the control group(P=0.023).After the intervention,compared to control group the intervention group had a higher proportion of patients taking antihypertensive drugs,with lower systolic and diastolic blood pressure(P<0.05).After the intervention,the increase rate of HDL-C in the intervention group was more than that in the control group,and the decrease rate was less than that in the control group(χ2=6.65,P=0.036).Conclusion Family doctor contract services can reduce the risk factors of ASCVD,and personalized family doctor contract services can further improve the effects in the prevention and control of ASCVD.However,the effects might be insignificant and inconsistent for the ASCVD risk factors with deeper management requirements or no specific management measures,which highlights the complexity and diversity of ASCVD prevention and control,calling for multi-level and multi-faceted thinking and exploration.