基于中断时间序列的脑卒中患者健康管理模式实施效果评价

The evaluation of the implementation effect of health management models for stroke patients based on interrupted time series

目的 系统评价脑卒中患者健康管理服务创新试点项目对脑卒中患者健康指标的改善情况。方法 采用自行设计的“脑卒中患者健康管理服务项目随访表”收集相关数据,采用中断时间序列对干预项目实施的全过程进行历时评价与比较分析。结果 2023年3月—2024年2月,研究对象血压、血糖、总胆固醇、高密度脂蛋白胆固醇以及用药依从性等指标存在不同程度的下降趋势,变化趋势差异有统计学意义(P<0.05)。但是BMI始终高于常规标准值上限(24 kg/m~2),甘油三酯在干预期间总体呈现上升趋势,低密度脂蛋白胆固醇在干预末期仍高于脑卒中患者的理想阈值(2.6 mmol/L)。结论 应针对相关指标制定营养支持与运动管理方案,关注脑卒中患者的心血管健康,做好多专业团队的有效沟通与合作,为脑卒中患者提供全流程、全方位的持续性、综合性照护服务。

Objective To systematically evaluate the improvement of health indicators in stroke patients in the innovative pilot project of health management services for stroke patients.Methods A self-designed“follow-up form of health management services for stroke patients”was used to collect relevant data,and the interrupted time series was used to conduct diachronic evaluation and comparative analysis of the whole process of the intervention project.Results From March 2023 to February 2024,the indexes of blood pressure,blood glucose,total cholesterol,high density lipoprotein,and medication compliance of the sample population showed different degrees of decline,and the change trend was statistically significant(P<0.05),but the BMI level of the sample population was always higher than the upper limit of the conventional standard value(24 kg/m2),the triglyceride level showed an overall upward trend during the intervention period,and the low density lipoprotein level was still higher than the ideal threshold of stroke patients(2.6 mmol/L)at the end of the intervention.Conclusion Nutritional support and exercise management plans should be developed based on relevant indicators,with attention paid to the cardiovascular health level of stroke patients.Effective communication and cooperation among professional teams should be carried out to provide continuous and comprehensive care services for stroke patients throughout the entire process and in all aspects.