社区与家庭一体化管理模式在农村地区冠心病二级预防中的探索  

The integration of community and family management model in rural areas in the secondary prevention of coronary heart disease

作　　者：李富军 杨利娟[1] 黄晓鸥 刘丽英[1] 康林[1] 赵宇[1] 王立新[1] LI Fu-jun;YANG Li-juan;HUANG Xiao-ou(Department of Cardiology, Beijing Yanqing District Hospital (the Third Hospital of Peking University, Yanqing Hospital), Beijing 102100, China)

机构地区：[1]北京市延庆区医院(北京大学第三医院延庆医院)心内科

出　　处：《中华全科医学》2019年第8期1360-1362,共3页Chinese Journal of General Practice

基　　金：首都全科医学研究专项课题基金(16QK16)

摘　　要：目的探索建立一种以助理全科医师为主体,社区卫生服务中心与患者家庭对冠心病出院患者进行连续性管理,适合现阶段农村基层医疗卫生条件的冠心病二级预防新模式。方法将2016年6月-2017年6月在北京市延庆区医院确诊的100例冠心病患者作为实验组纳入"社区与家庭一体化管理"模式进行冠心病二级预防管理并随访12个月,回顾前1年(2015年6月-2016年6月)在北京市延庆区医院确诊的100例冠心病患者二级预防效果为对照组,就2组患者对冠心病知识知晓率(问卷调查)、循证药物治疗的依从性(家属对患者服药种类及次数进行记录)、冠心病危险因素(每3个月测量1次血压、血糖、血脂、体重及戒烟率)的控制及不良心血管事件发生率进行对比研究。结果经"社区与家庭一体化管理"模式进行冠心病二级预防的患者,对冠心病知识掌握率为74%(对照组为38%)、服药依从性为88%(对照组为46%)均明显提高(均P<0.05);吸烟、控制体重等不良生活方式改善不明显(P>0.05),低密度脂蛋白、血压、血糖等指标较入院时显著改善(均P<0.05),2组不良心血管事件发生率比较差异无统计学意义(P>0.05)。结论"社区与家庭一体化管理"冠心病二级预防模式保障了对出院患者的连续性管理,明显提升冠心病患者对所患疾病的认识,有效控制冠心病危险因素,提高循症药物治疗的依从性。Objective To explore and establish a new mode of secondary prevention of coronary heart disease with assistant general practitioners as the main body, community health service centers and patients’ family members conducting continuous management of coronary heart disease discharged patients, which is suitable for the current rural grassroots medical and health conditions. Methods A total of 100 cases of coronary heart disease patients diagnosed in Beijing Yanqing district hospital from June 2016 to June 2017 were selected as experimental group into "the integration of community and family management" model for secondary prevention of coronary heart disease management and follow-up of 12 months. A review was made of 100 cases of coronary heart disease(CHD) patients with secondary prevention effect 1 year earlier(from June 2015 to June 2016) treated in Beijing Yanqing district hospital who was selected as the control group. A comparative analysis was made regarding to coronary heart disease knowledge awareness(questionnaire) and evidence-based medicine compliance(families of patients with medication type and number of records), coronary heart disease risk factors(every 3 months 1 time of blood pressure measurement), the control of blood glucose, lipids, body weight and smoking cessation rate and the incidence of adverse cardiovascular events. Results Via the "integration of community and family management" model for secondary prevention of coronary artery disease patients, 74%(control, 38%) for coronary heart disease knowledge rate, medication adherence by 88%(control, 46%) were significantly increased(P<0.05);smoking, control weight and lifestyle improvement were not obvious(P>0.05);low density lipoprotein, blood pressure, blood glucose were significantly improved(all P<0.05). There was no significant difference in the incidence of adverse cardiovascular events between the two groups(P>0.05). Conclusion The "integrated community and family management" mode of secondary prevention of coronary heart disease ensure

关 键 词：全科医师 “社区与家庭”模式 冠心病二级预防 

分 类 号：R541.4[医药卫生—心血管疾病] R197.61[医药卫生—内科学]