中国农村卫生事业管理2026，Vol.46Issue(7)：493-499,7.DOI:10.19955/j.cnki.1005-5916.2026.07.007
"千县工程"背景下县域PCI术后延续护理模式创新研究
Innovative study on the Post-PCI transitional care model in counties under the background of the"Thousand Counties Project"
摘要
Abstract
Objective To construct a whole-process management model of multi-platform information-based transitional care for the post-Percutaneous Coronary Intervention(PCI)management problems in counties under the background of the"Thousand Counties Project",and to explore the implementation effects after clinical application,providing a basis for policy transformation.Methods 104 patients after PCI in a county-level hospi-tal from January 2024 to January 2025 were selected as the research subjects and divided into the experimental group and the basic group using the interval randomization method.The experimental group adopted a multi-plat-form information-based transitional care whole-process management model that integrated county-level medical com-munity resources;the basic group implemented routine discharge follow-up.After 3 and 6 months of intervention,the patients' health behaviors and medication adherence were assessed,and cardiac function indicators and the re-admission rate within 6 months were monitored.Results The scores of each dimension of the Health-Promoting Lifestyle Profile-Ⅱ(HPLP-Ⅱ)in the experimental group were higher(P＜0.05);the self-efficacy of chronic dis-eases and the self-management ability of coronary heart disease were significantly improved(P＜0.001);the medication adherence was higher(P＜0.001),and the improvement of left ventricular end-diastolic diameter was more significant(P=0.009);the readmission rate was significantly reduced(1.92％vs 15.38％,P＜0.005).Conclusions The multi-platform information-based transitional care whole-process management model effectively improves the health behaviors and medication adherence of PCI patients,reduces the risk of readmission,and pro-vides a practical path for county-level medical-prevention integration and the"Healthy China 2030"chronic dis-ease management goals.关键词
千县工程/PCI术后延续护理/多平台协同/县域卫生服务/再入院率/慢性病管理Key words
Thousand Counties Project/Post-PCI transitional care/Multi-platform collaboration/County-level health services/Readmission rate/Chronic disease management分类
医药卫生引用本文复制引用
朱翠萍,陈丽丽.."千县工程"背景下县域PCI术后延续护理模式创新研究[J].中国农村卫生事业管理,2026,46(7):493-499,7.基金项目
浙江省医药卫生科技计划项目(2024XY221) （2024XY221）
