医院与社区联合进行院外冠心病患者的规范化管理  

Management of coronary atherosclerotic heart disease through an alliance of community and hospital

作　　者：钟益刚[1] 王宁夫[1] 李虹[1] 郭士遵[1] 周占林[1] 童国新[1] 林坚[3] 盛国安 汪一波 徐鹏[1] 刘宇[1] 邹建伟[1] 

机构地区：[1]南京医科大学附属杭州医院杭州市第一人民医院心内科,310006 [2]浙江省临安市人民医院 [3]杭州市上城区人民医院

出　　处：《中华医学杂志》2010年第38期2675-2678,共4页National Medical Journal of China

基　　金：杭州市科技局重点项目（20080333Q03）

摘　　要：目的 探索医院与社区联合规范化管理在降低院外冠心病患者的终点事件及提高患者依从性方面的价值.方法 入组15个社区冠心病患者共2000例,同意随访并签署患者随访管理合作意向书者达1642例,对其中10个社区的卫生服务机构人员进行培训并建立和实施患者强化管理计划,列为强化管理组,其余5个社区不进行医师培训,仅对患者进行常规门诊管理,列为非强化管理组.两组患者均随访23个月.结果 强化管理组患者全因死亡、心源性死亡、心血管事件再入院等一级终点事件的发生风险与非强化管理组相比,分别低36.5%（OR 0.635,95%CI 0.478～0.854）、41.5%（OR 0.585,95%CI 0.428～0.800）、56.1%（OR 0.439,95%CI 0.315～0.612）.强化管理组患者心功能控制明显好于非强化管理组,但心功能Ⅲ级患者（3.6%比7.7%,P＞0.05）,Ⅳ级患者（1.6%比6.4%,P＜0.05）均有增加.强化管理组与非强化管理组的阿司匹林肠溶片使用依从性下降明显（分别8.4%、8.7%,P＜0.05）,但其他冠心病治疗基础药物的使用依从性均较好.结论 通过医院与社区联合进行冠心病规范化管理,显著降低患者全因死亡、心血管事件再入院等一级终点事件的发生率,改善心功能,提高患者生活质量.Objective To evaluate the effect of out-hospital normalized management of coronary heart disease （CAD） on the end point events such as mortality, readmission, etc, and on the compliance of patients through normalized management by an alliance of community and hospital. Methods The samples were comprised of a total of 2000 patients in 15 communities. And 1642 patients agreed to a follow-up and signed a consent form. Ten communities were chosen as the intensive management group in which community clinicians were trained and the patient management plan was proposed and carried out. The remaining 5 communities were taken as the control group in which the community clinicians were not trained and the patients received only general management. Both groups received a follow-up of 23 months. Results Compared with the control group, the intensive manage group showed a lower risk of all-cause death, cardiac death and readmission due to cardiovascular events （CVE）. They declined by 36.5% （OR 0. 635,95% CI 0.478-0.854）,41.5%（OR0.585,95%CI 0.428-0.800） and 56.1%（OR0.439,95%CI0.315-0.612）respectively. The proportion of patients with NYHA Ⅲ in the intensive management and control groups increased by 3.6% and 7.7% while that of the counterparts of NYHA Ⅳ in two groups increased by 1.6% and 6. 4% respectively. The cardiac function in the patients of intensive management group was significantly superior to that in control group. Patients in both groups displayed an acceptable compliance to cardiac medications except for aspirin. The proportion of aspirin in the intensive management and control groups increased by 8.4% and 8.7% respectively （P 〈 0.05）. Conclusion Through normalized management provided by an alliance of community and hospital, the rates of all-cause death and readmission due to CVE decrease significantly concurrently with an improvement of cardiac function and quality of life in CAD patients.

关 键 词：冠状动脉疾病 医院 社区 疾病管理 

分 类 号：R686[医药卫生—骨科学]