社区老年慢性心力衰竭患者的随访干预调查  

Survey on follow-up intervention in community-based elderly patients with chronic heart failure

作　　者：徐先静[1] 段明勤[1] 黄改荣[1] 曹选超[1] XU Xian-jing;DUAN Ming-qin;HUANG Gai-rong;CAO Xuan-chao(Department of Geriatrics,Henan Province People's Hospital,Zhengzhou,Henan 450003,China)

机构地区：[1]河南省人民医院老年医学科,河南郑州450003

出　　处：《中国卫生检验杂志》2021年第16期2026-2029,共4页Chinese Journal of Health Laboratory Technology

摘　　要：目的观察三甲医院多学科团队(Multidisciplinary Team,MDT)对老年慢性心力衰竭患者的随访干预效果,为社区老年人慢性心力衰竭及其他慢性疾病管理提供思考和方向。方法纳入郑州市两个社区60岁及以上Ⅱ级~Ⅲ级(NYHA分级)的慢性心力衰竭患者共538例,其中一个社区进行MDT随访干预(MDT组,275例),另一个社区不进行干预(对照组,263例),干预前及1年后观察入组人群的生活质量状况,心功能指标及心力衰竭再住院率、急诊干预次数、病死率的变化。结果 MDT组较对照组明尼苏达生活质量评分明显降低,差异有统计学意义(P <0.01);干预后6 min步行距离、NT-pro BNP心功能指标MDT组明显优于对照组,差异均有统计学意义(P <0.01);随访期间两组患者均无死亡,MDT组心力衰竭再住院率、急诊干预次数较对照组显著降低,差异有统计学意义(P <0.01)。结论三甲医院多学科团队对社区老年慢性心力衰竭患者的随访干预具有积极作用,该研究对探讨我国老年慢性心力衰竭的社区管理模式及其他慢性疾病的管理具有一定的借鉴意义。Objective To evaluate the efficacy of follow-up intervention in in community-based elderly patients with chronic heart failure by a multidisciplinary team( MDT) from a third-grade A hospital,so as to provide clinical basis for the management of chronic heart failure and other chronic diseases in community-based elderly patients. Methods A total of 538 patients aged 60 or above with chronic heart failure [GRADE Ⅱ-Ⅲ( NYHA grade) ] were included in two communities in Zhengzhou. MDT follow-up intervention was performed in one community( MDT group,275 cases),and not performed in the other community( control group,263 cases). The life quality,the changes of cardiac function index,re-hospitalization rate,emergency intervention frequency and mortality rate of the enrolled population were observed before intervention and 1 year after intervention. Results The score of Minnesota quality of life in MDT group was significantly lower than that in the control group,and the difference was statistically significant( P < 0. 01);The six minutes walking distance and NT-pro BNP in MDT group were significantly better than those in the control group,and the difference was statistically significant( P < 0. 01);There was no death in the two groups during the following-up,and the rate of re-hospitalization and the number of emergency interventions in MDT group were significantly lower than those in the control group,and the differences were statistically significant( P < 0. 01). Conclusion MDT from major hospital provides a positive effect in disease intervention in the community-based elderly patients with chronic heart failure,which may be helpful in exploring the community management mode of the elderly patients with chronic disease except chronic heart failure.

关 键 词：多学科团队 慢性心力衰竭 随访干预 社区 

分 类 号：R541.6[医药卫生—心血管疾病]