缺血性脑卒中早期康复临床路径的随机对照研究

发布时间：2018-03-08 02:07

本文选题：临床路径　切入点：脑卒中　出处：《南京医科大学》2016年博士论文　论文类型：学位论文

【摘要】：目的：分别从临床功能和卫生经济学角度评估缺血性脑卒中早期康复临床路径联合康复方案的效果,为脑卒中早期康复临床路径的优化和推广提供数据支持。方法：采用随机、单盲、平行对照、多中心的前瞻性研究,符合纳入标准的缺血性脑卒中患者286例,随机分为临床路径组(n=143)和常规康复组(n=143)。临床路径组入组后进入脑卒中早期康复临床路径及相应的康复治疗方案,常规康复组采取一般康复治疗,不进入临床路径,对康复治疗内容及时间不做要求。分别于入组前和临床路径介入后第三周末(即出院时)采用主要结局指标改良Barthel指数(Modified Barthel Index, MBI)以及次要结局指标脑卒中ICF核心分类组合简版、简化Fugl-Meyer运动功能评分量表(Fugl-Meyer Motor Assessment Scale, FMA)、Gugging吞咽功能评估(Gugging Swallowing Screen, GUSS)对两组患者的日常活动能力、综合功能水平、运动功能、吞咽功能进行评定和分析。并采用成本-效果分析、增量分析评价两组患者的卫生经济学指标。结果：(1)259例患者纳入统计,其中临床路径组136例,男性90例,女性46例,常规康复组123例,男性91例,女性32例。(2)临床路径组康复治疗前后的MBI差值(MBI1-MBI0)、MBI改善程度((MBI1-MBIo) /(100-MBI0)×100%)均显著高于常规康复组,差异有统计学意义(P0.05)。(3)临床路径组康复治疗前后脑卒中ICF核心分类组合简版总分差值高于常规康复组,差异有统计学意义(P0.05)。(4)两组患者康复治疗前后FMA差值(FMA1-FMA0)及FMA改善程度((FMA1-FMA0)/(100-FMAo)×100%)比较差异无统计学意义(P0.05)。(5)71例患者伴有吞咽障碍,临床路径组(n=39)患者康复治疗前后GUSS差值高于常规康复组(n=32),差异有统计学意义(P0.05)。(6)临床路径组日常活动能力MBI每提高1分,住院总费用(889.92元)及康复费用(344.72元)均低于常规康复组(1161.22和685.68元)；增量分析表明临床路径组MBI每多提高1分,需额外花费的住院总费用和康复费用分别是196.73和95.50元。敏感度分析也表明临床路径组MBI每提高1分的花费比常规康复组少。结论：早期康复临床路径结合规范化的康复方案能提高缺血性脑卒中患者的日常活动能力,改善患者的功能,并能提高住院康复费用的利用效率,节约康复资源。
[Abstract]:Objective: to evaluate the effect of combined rehabilitation regimen in early rehabilitation of ischemic stroke from the point of view of clinical function and health economics, and to provide data support for optimizing and popularizing the clinical pathway of early rehabilitation of cerebral apoplexy. A single blind, parallel controlled, multicenter prospective study of 286 patients with ischemic stroke that met the inclusion criteria, The patients were randomly divided into two groups: the clinical pathway group and the routine rehabilitation group. The clinical pathway group entered into the early stage of stroke rehabilitation clinical pathway and the corresponding rehabilitation treatment plan. The routine rehabilitation group received general rehabilitation treatment, but did not enter the clinical path. The content and time of rehabilitation treatment were not required. The main outcome index, modified Barthel index (MBI), and the ICF core classification combination of secondary outcome index of stroke were adopted before entering group and at the end of the third week after clinical pathway intervention (i.e. when discharged from hospital). The simplified Fugl-Meyer motor function scale was used to evaluate and analyze the daily activity ability, comprehensive functional level, motor function and swallowing function of the two groups by using the Fugl-Meyer Motor Assessment scale, FMA-Gugling swallowing function to evaluate and analyze the daily activity ability, comprehensive functional level, motor function and swallowing function of the two groups, and cost-effect analysis was used to evaluate and analyze the daily activity ability, comprehensive functional level, motor function and swallowing function of the two groups. Results there were 136 cases in the clinical pathway group, 90 cases in the male group, 46 cases in the female group, 123 cases in the routine rehabilitation group, 91 cases in the male group, and there were 136 cases in the clinical pathway group, 90 cases in the male group, 46 cases in the female group, 123 cases in the routine rehabilitation group and 91 cases in the male group. The difference of MBI before and after rehabilitation treatment in 32 female patients with clinical pathway group was significantly higher than that in the routine rehabilitation group, and the improvement degree of MBI1-MBIo- / 100-MBI0) was significantly higher than that in the conventional rehabilitation group. The difference of total score of ICF core classification combination before and after rehabilitation in the clinical pathway group was higher than that in the routine rehabilitation group. There was no significant difference in the difference of FMA between the two groups before and after rehabilitation treatment (FMA1-FMA0) and the degree of improvement of FMA (FMA1-FMAO / 100-FMAo100) 脳 100). There was no significant difference between the two groups (P0. 05%, P 0. 05, P < 0. 05, P < 0. 05, P < 0. 05, P < 0. 05, P < 0. 05, P < 0. 05, P < 0. 05, P < 0. 05). The difference of GUSS before and after rehabilitation in the clinical pathway group was higher than that in the routine rehabilitation group, and the difference was statistically significant (P < 0.05). The difference was significant (P < 0.05). The daily activity ability (MBI) of the clinical pathway group was increased by 1 point. The total cost of hospitalization (889.92 yuan) and the cost of rehabilitation (344.72 yuan) were lower than that of routine rehabilitation group (1161.22 and 685.68 yuan). The total hospitalization cost and rehabilitation cost were 196.73 and 95.50 yuan respectively. Sensitivity analysis also showed that the cost of each increase of MBI in the clinical pathway group was less than that in the routine rehabilitation group. Conclusion: the clinical pathway of early rehabilitation combined with standardization is less than that of the routine rehabilitation group. The rehabilitation program can improve the daily activity ability of patients with ischemic stroke. It can improve the function of patients, improve the utilization efficiency of hospitalization rehabilitation costs, and save rehabilitation resources.
【学位授予单位】：南京医科大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R743.3

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