上海市某社区卒中高危老年人群筛查与干预管理实施效果评价

Evaluation of the effectiveness of screening-intervention management in elderly population at high risk of stroke in a community in Shanghai

目的评价社区卒中高危老年人群筛查与干预管理方案的实施效果。方法选择2019年5月至2022年7月参加上海市奉贤区泰日社区年度健康体检的老年(年龄≥60岁)人群作为筛查与干预对象。于2019和2020年分2个年度分别进行第一轮卒中高危人群筛查,2021年和2022年依次对2019和2020年的筛查人群进行第二轮卒中高危人群筛查(复查),选择2轮筛查中均接受过卒中高危筛查的人群(重叠人群)作为本研究的观察对象。采用脑血管功能积分值对卒中高危人群进行筛查,75~100分为非高危,<75分为高危,其中50~74、25~49、0~24分依次为轻、中、重度危险。收集所有筛查人群的基线和复查资料,包括收缩压、舒张压、超重或肥胖情况(体质量指数≥24 kg/m2)、空腹血糖、糖化血红蛋白、三酰甘油、总胆固醇、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇、血尿酸。完成筛查后,在筛查现场对被筛查者进行检测报告解读和首诊干预,并将筛查结果录入健康体检档案。首诊干预包括生活方式干预、危险因素干预和高危个体的治疗性干预。生活方式干预和危险因素干预采取发放卒中预防科普手册和个体化面对面指导的方式。高危个体的治疗性干预根据卒中风险评估结果、相关慢性病患病情况等指导抗血小板聚集药物治疗、他汀类药物治疗及脑血管的进一步检查与治疗等。项目实施前回顾性调查2018年度该社区的卒中发病情况,以比较卒中筛查-干预的年度变化。在实施干预管理的过程中进行全社区户籍人口卒中发病监测,监测方法为每年进行1次卒中发病登记,并与奉贤区疾病预防控制中心和金汇镇泰日派出所合作获取疾病预防控制中心提供的2018至2022年该社区卒中发病监测资料和派出所提供的死亡登记信息。结果2轮筛查重叠并符合纳入排除标准的对象共5188名,男2269名,女2923名,第一轮筛查时的年龄为60~93岁,平均年龄(68±6)岁,其中60~64、65~69、70~74、≥75岁年龄组占比分别为30.3%、34.7%、21.1%和14.0%。(1)筛查-干预后收缩压、舒张压、空腹血糖、三酰甘油、低密度脂蛋白胆固醇水平升高者的比例均下降(分别为49.4%比57.3%、26.6%比28.7%、9.6%比10.9%、14.7%比17.0%、2.4%比3.3%;均P<0.05),但高尿酸血症者比例增加(15.8%比13.1%,P<0.01),差异均有统计学意义。(2)2018年筛查-干预方案实施前该社区卒中发病率为332.1/10万,2019—2022年实施筛查-干预方案期间社区的卒中发病率分别为335.0/10万、270.8/10万、235.0/10万和193.6/10万。2019—2022年该社区缺血性卒中(χ_(趋势)^(2)=8.350,P=0.004)和卒中(χ_(趋势)^(2)=9.910,P=0.002)的发病率均呈下降趋势,出血性卒中的发病率未见下降趋势(χ_(趋势)^(2)=1.636,P=0.201)。(3)参与卒中高危筛查的5188名老年人群的基线和复查脑血管功能积分值中位数分别为82.50(52.50,98.75)分和88.50(59.00,100.00)分,卒中高危率分别为39.8%和35.6%;干预后复查的脑血管功能积分值较基线上升,卒中高危率下降,筛查-干预前后卒中风险等级的分布差异有统计学意义(均P<0.01)。结论结合社区老年人健康体检和家庭医师团队服务实施卒中高危人群筛查与干预管理方案,能够显著降低社区卒中发病率、高危率和危险因素暴露水平。

Objective To evaluate the effectiveness of screening-intervention management program for high risk population of stroke in community.Methods Participants aged≥60 years old in Tairi Community,Fengxian District,Shanghai from May 2019 to July 2022 were selected as screening and intervention objects.The first round of stroke high-risk group screening was conducted in 2019 and 2020 in two years respectively,and the second round of stroke high-risk group screening(re-screening)was conducted in 2021 and 2022 respectively for the 2019 and 2020 screening groups,and the groups who had received stroke high-risk screening in both rounds of screening(overlapping groups)were selected as the observation objects of this study.The cerebrovascular function score was used to screen the high-risk individuals of stroke,75-100 was classified as non-high-risk,<75 were classified as high risk,among which 50-74,25-49,0-24 were light,medium and severe risk,in turn.Baseline and follow-up data were collected for all screening groups,including systolic blood pressure,diastolic blood pressure,overweight or obesity,fasting blood glucose,glycated hemoglobin,triglyceride,total cholesterol,low-density lipoprotein cholesterol,high-density lipoprotein cholesterol,and blood uric acid.After the completion of screening,the test report interpretation and first diagnosis intervention were carried out on the screening site,and the screening results were recorded into the health examination file.The first intervention includes lifestyle intervention,risk factor intervention and therapeutic intervention for high-risk individuals.Lifestyle intervention and risk factor intervention were conducted through the distribution of popular science handbook for stroke prevention and individualized face-to-face guidance.Therapeutic intervention for high-risk individuals was guided by anti-platelet aggregation drug therapy,statin therapy,and further examination and treatment of cerebral vessels according to stroke risk assessment results and the incidence of related chronic diseases.Prior to the implementation of the project,the incidence of stroke in the community in 2018 was retrospectively investigated to compare annual changes in stroke screening-intervention.In the process of implementation of intervention management,stroke incidence monitoring of the whole community registered population was carried out,and the monitoring method was to conduct stroke incidence registration once a year,and cooperate with the disease control and community police station to obtain the community stroke incidence monitoring data and death registration information provided by the police station from 2018 to 2022.Results A total of 5188 subjects who completed both the initial screening and the follow-up screening and met the inclusion and exclusion criteria were identified,of whom 2269 were male and 2923 were female.The age of participants ranged from 60 to 93 years at the time of the first round of screening,with a mean age of(68±6)years.The proportions of subjects in the age groups of 60-64,65-69,70-74,and≥75 years were 30.3%,34.7%,21.1%,and 14.0%,respectively.(1)After screening and intervention,the proportion of individuals with increased systolic blood pressure,diastolic blood pressure,fasting blood glucose,triglyceride,and low-density lipoprotein cholesterol all decreased(respectively 49.4%vs.57.3%,26.6%vs.28.7%,9.6%vs.10.9%,14.7%vs.17.0%,2.4%vs.3.3%;all P<0.05),but the proportion of individuals with hyperuricemia increased(15.8%vs.13.1%,P<0.01),with statistically significant differences.(2)Before the implementation of the screening-intervention program in 2018,the stroke incidence rate in the community was 332.1/100000.The stroke incidence rates in the community during the period from 2019 to 2022 after the implementation of the screening-intervention program were 335.0/100000,270.8/100000,235.0/100000,and 193.6/100000,respectively.The incidence rates of ischemic stroke(χ_(trend)^(2)=8.350,P=0.004)and stroke(χ_(trend)^(2)=9.910,P=0.002)decreased during the period from 2019 to 2022,while the incidence rate of hemorrhagic stroke did not show a decreasing trend(χ_(trend)^(2)=1.636,P=0.201).(3)The median baseline and follow-up cerebrovascular function scores for the 5188 elderly individuals undergoing residual stroke risk screening were 82.50(52.50,98.75)and 88.5(59.00,100.00),respectively,with stroke risk rates of 39.8%and 35.6%before and after intervention,respectively.After intervention,the follow-up cerebrovascular function scores increased compared to the baseline,and the stroke risk rate decreased.The distribution of stroke risk levels before and after screening-intervention had statistically significant differences(P<0.01).Conclusion Implementing a stroke high-risk population screening-intervention management program for the elderly in the community,combined with health examinations and family doctor team services,can significantly reduce the incidence,high-risk rate,and exposure level of risk factors for stroke in the community.