基于社区医养护一体化签约血脂异常分层管理效果评价

发布时间：2018-04-29 20:41

  本文选题：社区全科医生签约 + 血脂异常　； 参考：《浙江大学》2017年硕士论文

【摘要】：目的:探索基于社区医养护一体化签约血脂异常分层综合管理模式,评价该模式对血脂异常患者的管理效果。方法:本文采用队列研究,选取杭州市某街道社区居民2586例,筛查出血脂异常居民774人,其中签订杭州市医养护一体化签约服务协议的居民406人,未签约居民368人,再从中分别共随机抽取420例血脂异常患者作为研究对象,其中签订协议者220例纳入干预组,未签订协议者200例纳入对照组。干预组由全科医生团队进行一对一签约,以问卷的形式收集研究对象的相关信息,由社区护士建立健康档案和慢性病档案,并进行为期12个月的团队分层综合管理。首先根据分层管理办法,由全科医生团队管理,如管理期3个月内随访不达标,则转诊到血脂异常防治首席医生团队处。由首席医生和首席护士进行个性化指导和诊疗方案调整,继续进行3个月随访,达标者转回到原全科医生团队进行管理,不达标者转诊到心血管专科诊疗,由心血管专科医生调整治疗方案,同时全科医生团队追踪随访。对照组建立个人健康档案,保持原有的社区治疗管理模式,即全科医生药物治疗,社区护士健康宣教和定期随访。12个月的管理期结束后,采用SPSS 19.0软件,使用非条件多因logistic回归分析法,分析干预组和对照组的服药依从性,不良生活方式改变,血脂相关指标(TC、LDL-C、TG、HDL-C、FBG及UA),组内高TC血症、高TG血症、高LDL-C血症、低HDL-C血症、超重/肥胖、腹型肥胖、高血压、高尿酸血症、高血糖等的比率,组内干预前后中高危人群的比率等,探索社区医养护一体化签约服务下团队分层综合管理对血脂异常患者的效果。结果:血脂异常患者管理12个月后,干预组服药依从性明显提高,服药率增加,差异有统计学意义(P＜0.05);干预组的不良生活方式改变率高于对照组,干预组的TC、LDL-C、TG、FBG及UA下降比率和HDL-C升高比率也高于对照组,差异均有统计学意义(P0.05)。干预组的高TC血症、高TG血症、高LDL-C血症、低HDL-C血症、超重/肥胖、腹型肥胖、高血压、高尿酸血症患者下降比率,中高危人群下降比率,均高于对照组,差异有统计学意义(P0.05),而两组间的高血糖率变化差异无统计学意义(P0.05)。结论:医养护一体化签约服务下团队分层综合管理,明显提高了血脂异常患者的服药依从性,更有效的改变了患者的不良生活方式,减少了代谢异常发生率,降低了中高危人群比率,从而有效提高了血脂异常患者的管理效果。
[Abstract]:Objective: to explore the stratified and integrated management model of dyslipidemia based on community medicine and maintenance, and to evaluate the effect of this model on patients with dyslipidemia. Methods: a cohort study was conducted to select 2586 residents of a street community in Hangzhou, and 774 residents with dyslipidemia were screened out. A total of 420 patients with dyslipidemia were randomly selected from the study group, of which 220 were included in the intervention group and 200 in the control group. The intervention group was contracted one-to-one by the team of general practitioners. The relevant information of the subjects was collected by questionnaire, and the health and chronic disease files were established by community nurses, and the team was managed by stratified and integrated management for 12 months. Firstly, according to the hierarchical management method, the general practitioner team manages, if the management period is not up to the standard within 3 months, then referred to the chief doctor team for the prevention and treatment of dyslipidemia. By the chief doctor and chief nurse to carry on the individuation instruction and the diagnosis and treatment plan adjustment, continue to carry on the follow-up for 3 months, the person who meets the standard returns to the original general practitioner team for management, the person who does not meet the standard is referred to the cardiovascular specialized diagnosis and treatment, The regimen was adjusted by cardiovascular specialists and followed up by a team of general practitioners. In the control group, the individual health records were established, and the original management model of community treatment was maintained, that is, drug therapy by general practitioners, health education by community nurses and regular follow-up. After 12 months of management, SPSS 19.0 software was used. Non-conditional multifactorial logistic regression analysis was used to analyze the drug compliance, the changes of poor lifestyle, the related indexes of blood lipids, hyperTC, hypertriglyceridemia, high LDL-C, low HDL-C, overweight / obesity in the intervention group and control group. The rates of abdominal obesity, hypertension, hyperuricemia, hyperglycemia, and the ratio of high risk group before and after intervention were explored to explore the effect of group stratification and comprehensive management on patients with dyslipidemia under the integrated contract service of community medicine and maintenance. Results: after 12 months of management, the compliance and the rate of medication in the intervention group increased significantly (P < 0.05), and the change rate of the bad lifestyle in the intervention group was higher than that in the control group. In the intervention group, the decrease rate of TCU LDL-CU FBG and UA and the increase rate of HDL-C were also higher than those in the control group, and the difference was statistically significant (P 0.05). The decreasing rates of hyperTC, hypertriglyceridemia, hyper, low HDL-C, overweight / obesity, abdominal obesity, hypertension and hyperuricemia in the intervention group were higher than those in the control group. The difference was statistically significant (P 0.05), but there was no significant difference in hyperglycemia between the two groups (P 0.05). Conclusion: under the service of integrated medical service and maintenance, the group management can obviously improve the compliance of patients with dyslipidemia, change their bad lifestyle more effectively, and reduce the incidence of abnormal metabolism. Reduce the ratio of high-risk population, thus effectively improve the management of patients with dyslipidemia.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R473.2
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本文编号：1821471