肢体残疾人医院-社区一体化健康管理网络平台构建及应用  

Establishment and application of integrative management network platform between hospital and community for physical disabled persons

作　　者：陈祢[1] 李超[2] 王宝兰[1] 王乐[3] 杨春生[1] 穆雅婷 侯天晨 CHEN Mi;LI Chao;WANG Baolan;WANG Le;YANG Chunsheng;MU Yating;HOU Tianchen(Department of Rehabilitation Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China;Department of Respiratory Critical Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China;Scientific Research Section, the First Affiliated Hospital of Xinjiang Medical University, Urumqi 830054, China)

机构地区：[1]新疆医科大学第一附属医院康复医学科,乌鲁木齐830054 [2]新疆医科大学第一附属医院呼吸重症医学科,乌鲁木齐830054 [3]新疆医科大学第一附属医院科研科,乌鲁木齐830054

出　　处：《新疆医科大学学报》2019年第10期1353-1358,共6页Journal of Xinjiang Medical University

基　　金：新疆维吾尔自治区自然科学基金(2015211C036);新疆医科大学人文社会科学基金(2013XYSK55)

摘　　要：目的探索建立基于网络的肢体残疾人医院-社区一体化健康管理平台,并评价其应用效果。方法建立基于网络的肢体残疾人医院-社区一体化健康管理平台,从2016年3月-2017年12月间纳入网络平台接受健康管理的患者中选取脑血管病后有肢体残疾且出院后继续下转至本院医联体二级医院康复医学科住院的患者87名,其中试验组46例,对照组41例。试验组接受基于网络的肢体残疾人医院-社区一体化健康管理平台管理,对照组患者出院后接受医院常规随访及社区卫生服务中心的常规健康管理,6个月后对患者健康管理频次及内容、血压水平、脑血管病再发次数、自我用药状况评分、肢体运动功能(Brunnstrom分级)及日常生活活动能力评分(Barthel指数)对健康管理效果进行评价。结果管理后2组患者门诊随访次数、社区健康管理人员入户或电话咨询次数及健康管理内容对比,差异均有统计学意义(P<0.05)。管理前2组患者血压水平对比,差异无统计学意义(P>0.05),管理后试验组患者收缩压下降值大于对照组,差异有统计学意义(P<0.05)。试验组在管理后患者自我用药状况更好,漏服降压药情况优于对照组,差异具有统计学意义(P<0.05)。2组患者脑血管病再发次数未见明显差异。管理前2组患者上肢、手、下肢功能及日常生活活动能力对比,差异无统计学意义(P>0.05),管理后试验组患者上肢、下肢功能及日常生活活动能力优于对照组,差异有统计学意义(P<0.05)。结论基于网络的肢体残疾人健康管理平台,依托三级康复服务体系,将残疾相关的慢性疾病与功能康复协同管理,可有效控制慢性疾病相关指标,提高肢体功能及生活自理能力,有利于实现残疾的全面预防。Objective To explore the establishment of a network-based hospital-community integrated health management platform for the disabled and evaluate its application effect. Methods To establish a network-based integrated health management platform for limb disability hospitals and communities. From March 2016 to December 2017, 87 patients with limb disability after cerebrovascular disease were selected and transferred to the Department of Rehabilitation Medicine of the Second Level Hospital of the Medical Association of the hospital. Forty-six patients in the experimental group and forty-one patients in the control group were selected. The experimental group was managed by a network-based hospital-community integrated health management platform, while the control group was adopted routine hospital follow-up and health management in community health service centers after discharge. After six months, The effect of health management was evaluated with data of frequency and content of health management, blood pressure, recurrence of cerebrovascular diseases, self-medication status, limb motor function(Brunnstrom grade) and activities of daily life(Barthel index). Results There were significant differences in number of follow-up visits, number of visits or telephone consultations by community health managers and health management contents between the two groups after management(P>0.05). There was no significant difference in blood pressure level between the two groups before management(P>0.05). After management, the systolic blood pressure of the experimental group decreased more than that of the control group(P<0.05). At the same time, the self-medication status of patients and the situation of missing antihypertensive drugs in the experimental group was better than those of the control group after management(P<0.05). There was no significant difference in the recurrence of cerebrovascular disease between the two groups due to limited sample size and short observation time. Compared with the control group, there was no s

关 键 词：肢体残疾 医院-社区 健康管理 网络平台 

分 类 号：R493[医药卫生—康复医学]