中国全科医学Issue(19)：2251-2254,4.DOI:10.3969/j.issn.1007-9572.2014.19.020
慢性心力衰竭社区疾病管理模式探索
Community-based Disease Management Model for Chronic Heart Failure
摘要
Abstract
Objective To understand the characteristics of people with chronic heart failure in community,based on which to make the suitable community management of the disease,next to discuss whether patients with chronic heart failure can benefit from the community management or not,so as to provides a new way for comprehensive prevention of chronic heart fail-ure. Methods (1) Self-designed questionnaire was used to investigate 288 patients with chronic heart failure in Liufu Street community of Changsha from March to April in 2012 who volunteered to take part in the community management about the charac-teristics of heart failure population. (2) Self-designed systematic management methods of chronic heart failure disease was used to interfere another 200 patients in the community drug treatment from May 2012 to May 2013,health education,lifestyle,self-management,etc. Patients' basic indexes controlling situation,usage rate of heart failure conventional drugs,awareness rate of heart failure knowledge,self-management,MNLF scores,frequency of hospitalization and incidence of cardiovascular events were observed before and after the intervention. Results (1)288 questionnaire were sent out,receiving 279 questionnaires with a recovering rate of 96. 88% and 274 valid questionnaires with an effective rate of 98. 21%. The average age of the patients was(68. 7 ± 10. 6);MNLF score was(22. 13 ± 14. 64);68. 61%(188/274)of the patients had low salt and low fat diets;41. 97%(115/274)measured their blood pressure on a regular basis;the control rate of blood pressure was 35. 40%(97/274);the active follow-up rate was 25. 18%(69/274)and the active accepting health education was 8. 03%(22/274). (2)After intervention,blood pressure control rate and heart rate control rate were higher than before(P﹤0. 05). The differ-ence of blood sugar control rate before and after intervention was not significant(P﹥0. 05). The usage rate of ACEI/ARB andβblockers,the awareness rate of heart failure knowledge,the percentage of patients who had low salt and low fat diets,measured blood pressure and blood rate regularly were all lower before intervention than after intervention ( P﹤0. 05 ) . 31 people visited hospitals through" the green channel",5 individuals through two-way referral and 5 through families follow-up. Conclusion Chronic heart failure disease management model in community can bring benefit to patients and is worthy of advocating.关键词
疾病管理/医院,社区/慢性心力衰竭Key words
Disease management/Hospitals,community/Chronic heart failure分类
医药卫生引用本文复制引用
单红,练宇,刘振芳,范文娟,郭莹,彭翔,彭建强,冯洁,唐铭翔,颜素岚,谢琼,邹琼超,傅庆华..慢性心力衰竭社区疾病管理模式探索[J].中国全科医学,2014,(19):2251-2254,4.基金项目
湖南省科学技术厅科技计划一般项目 （）
