医院与社区联合对慢性心力衰竭患者的院外干预研究

摘要

Objective To evaluate the efficacy of joint intervention of patients with the chronic heart failure (CHF) by hospital and community. Methods A total of 1894 discharged patients with chronic heart failure were enrol ed in present study. The patients were randomly divided into three groups:hospital group, community group and joint group. In hospital group, 631 patients were fol owed- up by specialists;in community group 633 patients were managed by trained general practitioners (GPs) alone. In joint group 630 patients received intervention by hospital specialists and GPs in community. Hospitals and communities developed the intervention programs for CHF patients jointly, and the community GPs, who were trained in general skil s and knowledge of standardized management for heart failure, implemented the programs. Results Compared to community groups, the overal mortality, cardiovascular mortality, heart failure readmission rate, emergency rate for heart failure of patients in hospital and joint groups were decreased by 17.53%, 15.71%, 19.11% and 18.15%, respectively (al P<0.05);and the heart functional class, left ventricular ejection fraction (LVEF), compliance, quality of life in joint group and the hospital group were significantly higher, worsening heart failure rate decreased by 15.59%, the average length of stay decreased by 4.56 d, inpatient medical cost decreased by 36.88%(al P<0.05). Conclusion The hospital and community joint intervention program can significantly improve the management of discharged patients with chronic heart failure, compared to management by community GPs alone.%　　目的探索医院与社区联合，对慢性心力衰竭患者进行院外规范化管理干预的有效途径和方式。方法选择出院的心力衰竭患者1894例，随机分为3组：医院社区联合组630例，其中男352例，女278例，平均年龄（69.39±12.46）岁；医院对社区全科医师进行心力衰竭诊疗技能及规范化管理知识的培训，医院与社区共同制定心力衰竭患者的干预方案，社区全科医师对心力衰竭患者进行防治管理。医院组631例，其中男359例，女272例，平均年龄（68.51±12.15）岁；由专科医师对心力衰竭患者进行院外随访干预。社区组633例，其中男356例，女277例，平均年龄（68.50±12.51）岁；不开展对社区全科医师的培训，由社区医师对心力衰竭患者进行随访。所有病例平均随访（12.0±1.6）个月。结果医院社区联合组、医院组患者的一级终点事件总病死率、心血管病死率、心力衰竭再住院率、心力衰竭急诊率较社区组分别下降17.53﹪、15.71﹪、19.11﹪、18.15﹪，差异均有统计学意义（均P＜0.05）；二级终点事件患者的心功能级别、左心室射血分数（LVEF）、依从性、生活质量均明显高于社区组，心力衰竭恶化率较社区组下降15.59﹪（均P＜0.05）；平均住院日较社区组减少4.56d（P＜0.05）；社区全科医师的心力衰竭诊治及管理水平明显提高。结论通过医院与社区联合对院外心力衰竭患者进行规范化管理干预，提高社区全科医师的心力衰竭诊治及管理水平，可显著降低心力衰竭患者的病死率、再次住院率、心力衰竭急诊率，改善患者的心功能、依从性、生活质量及预后，降低医疗费用。