家庭医生专病门诊主导下“1+N+N”组团式COPD患者管理效果初步分析

Preliminary analysis of the effect of “1+N+N” group for COPD patient management under the guidance by family doctor special outpatient clinic

目的:初步探索在社区卫生服务中心家庭医生社区专病门诊主导下,家庭医生团队+全专云结合(即“1+N+N”组团式)对慢性阻塞性肺疾病(COPD)综合管理效果。方法:收集2020年6月至2021年12月诊治的COPD患者123例,用随机数字表法将患者分为对照组60例和观察组63例,对照组采取社区常规管理,观察组以家庭医生社区专病门诊为主导,全科和专科医生通过信息化云结合,以家庭医生团队COPD病种管理为纽带,进行闭环式、综合性、连续性管理。两组均持续干预6个月。采用慢性阻塞性肺疾病评估测试(CAT)问卷和COPD患者生命质量问卷对患者进行评估。结果:干预后,观察组和对照组的CAT评分均低于各组干预前,且观察组CAT评分明显低于对照组(P <0.05)。干预后,观察组生命质量总分及各维度得分均高于干预前,且均明显高于同期对照组(P <0.05)。结论:在家庭医生社区专病门诊主导下,“1+N+N”组团式对COPD患者综合管理,能初步改善患者呼吸功能,提高患者生命质量。

Objective:To explore the comprehensive management effect of the combination of family doctor team + of general practice and specialty cloud(i.e.“1+N+N” cluster) on chronic obstructive pulmonary disease(COPD) under the guidance of the family doctor community special outpatient clinic of the community health service center.Methods:One hundred and twenty-three COPD patients diagnosed and treated from June 2020 to December 2021 were collected,and with the random number table method divided into a control group with 60 cases and an observation group with 63 cases,the control group took the community conventional management,and the observation group was under the guidance of the family doctor’s community outpatient clinic for special diseases,general practitioners and specialist doctors were combined through the information cloud,and the family doctor team’s COPD disease management was the link to carry out closed-loop,comprehensive and continuous management.Both groups were intervened for six months.Patients were assessed by the COPD assessment test questionnaire and the COPD patient quality of life questionnaire.Results:After intervention,the COPD assessment test scores in the observation group and the control group were lower than those before the intervention,and the COPD assessment test scores in the observation group were significantly lower than those in the control group(P<0.05).After the intervention,the total score of quality of life and the scores of each dimension in the observation group were higher than those before the intervention,and were significantly higher than those in the control group over the same period(P<0.05).Conclusion:Under the guidance of family doctors’ community outpatient service,“1+N+N” group comprehensive management of COPD patients can initially improve patients’ respiratory function and quality of life.