Effect analysis of community chronic heart failure patients managed by stages under the guidance of third-class hospitals
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摘要:
目的 社区医护在三甲医院心力衰竭(简称心衰)中心团队指导下对社区慢性心衰患者实施分期目标管理，分析管理前后目标效果的变化。 方法 2021年6—12月共入选760例30~92岁蚌埠市4家社区卫生服务中心的慢性心衰患者。由蚌埠医学院第一附属医院心衰中心医生指导社区医院按慢性心衰分期随访管理1年。主要观察指标包括管理前后患者对心衰的知晓率、标准化药物使用率、标准化药物达标率、生活质量评分、年住院率。 结果 患者对心衰的知晓率上升(55.45% vs. 97.63%，χ2=178.031，P=0.002)；心衰患者β受体阻滞剂使用率上升(22.75% vs. 92.89%，χ2=296.121，P=0.001)，血管紧张素转换酶抑制剂(ACEI)/血管紧张素受体阻滞剂(ARB)/沙库巴曲缬沙坦(ARNI)使用率上升(46.21% vs. 90.28%，χ2=186.173，P=0.002)，螺内酯使用率上升(63.27% vs. 91.70%，χ2=120.312，P=0.003)；β受体阻滞剂达标率上升(5.92% vs. 83.65%，χ2=328.231，P=0.001)，ACEI/ARB/ARNI达标率上升(12.56% vs. 82.70%，χ2=296.224，P=0.001)，螺内酯达标率上升(43.36% vs. 85.55%，χ2=178.321，P=0.002)；生活质量评分改善(t=95.311，P=0.003)，年住院率下降(45.50% vs. 24.41%，χ2=85.252，P=0.004)。 结论 三甲医院指导下社区慢性心衰患者按分期规范化管理模式，提高了心衰患者控制率和生活质量，减少再住院，也提高了社区医生心衰防治水平，从而推进分级诊疗政策持续实施。 Abstract:Objective Under the guidance of the team of the heart failure center of the third-class hospital, community doctors and nurses implemented target management for community patients with chronic heart failure by stages, and analyzed the target effect of management. Methods A total of 760 chronic heart failure patients aged 30-92 from four community health service centers in Bengbu City were selected from June to December in 2021. Community hospitals were guided by doctors from the Heart Failure Center of the First Affiliated Hospital of Bengbu Medical College to follow up and manage chronic heart failure in stages for one year. The main observation indicators included patient awareness of heart failure, standardized drug usage rate, standardized drug compliance rate, quality of life score, and annual hospitalization rate before and after management. Results The awareness rate of heart failure among patients increased (55.45% vs. 97.63%, χ2=178.031, P=0.002). The usage rate of β receptor blockers increased in heart failure patients (22.75% vs. 92.89%, χ2=296.121, P=0.001), the usage rate of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB)/angiotensin receptor and neprilysin inhibitor (ARNI) increased (46.21% vs. 90.28%, χ2=186.173, P=0.002), and the usage rate of spironolactone increased (63.27% vs. 91.70%, χ2=120.312, P=0.003). The compliance rate of β receptor blockers increased (5.92% vs. 83.65%, χ2=328.231, P=0.001), the compliance rate of ACEI/ARB/ARNI increased (12.56% vs. 82.70%, χ2=296.224, P=0.001), and the compliance rate of spironolactone increased (43.36% vs. 85.55%, χ2=178.321, P=0.002). The quality of life score improved (t=95.311, P=0.003), and the annual hospitalization rate decreased (45.50% vs. 24.41%, χ2=85.252, P=0.004). Conclusion Under the guidance of tertiary hospitals, the standardized management by stages for community chronic heart failure patients has improved the control rate and quality of life of heart failure patients, reduced readmission, and improved the level of heart failure prevention and treatment by community doctors, thus promoting the continuous implementation of graded diagnosis and treatment policies. -
表 1 社区入组规范化管理的慢性心衰患者一般资料(n=760)
Table 1. General data of chronic heart failure patients enrolled in standardized management in community (n=760)
项目 例数 占比(%) 年龄(岁) 30~59 242 31.85 60~79 287 37.76 80~92 231 30.39 性别 男性 417 54.87 女性 343 45.13 高血压 516 67.89 冠心病 365 48.03 其他心脏病 102 13.42 糖尿病 356 46.84 酗酒 168 22.11 肥胖 249 32.76 分期 心衰A期 201 26.45 心衰B期 137 18.02 心衰C、D期 422 55.53 
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表 2 社区慢性心衰C、D期患者管理前后相关指标比较
Table 2. Comparison of relevant indicators before and after the management of chronic heart failure stage C and D patients in the community
时间 例数 心衰知晓率(%) β受体阻滞剂使用率(%) ACEI/ARB/ARNI使用率(%) 螺内酯使用率(%) β-受体阻滞剂达标率(%) ACEI/ARB/ARNI达标率(%) 螺内酯达标率(%) 年住院率(%) 生活质量评分(x±s，分) 管理前 422 55.45(234/422) 22.75(96/422) 46.21(195/422) 63.27(267/422) 5.92(25/422) 12.56(53/422) 43.36(183/422) 45.50(192/422) 49.61±7.80 管理后 422 97.63(412/422) 92.89(392/422) 90.28(381/422) 91.71(387/422) 83.65(353/422) 82.70(349/422) 85.55(361/422) 24.41(103/422) 33.73±8.92 统计量 178.031a 296.121a 186.173a 120.312a 328.231a 296.224a 178.321a 85.252a 95.311b P值 0.002 0.001 0.002 0.003 0.001 0.001 0.002 0.004 0.003 注：a为χ2值，b为t值。
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表 3 社区慢性心衰A、B期患者管理前后心衰常见危险因素控制比较(x ±s)
Table 3. Comparison of common risk factors control of chronic heart failure in patients with stages A and B in the community before and after management(x ±s)
时间 例数 收缩压(mmHg) 舒张压(mmHg) 空腹血糖(mmol/L) LDL-C(mmol/L) BMI 管理前 338 169.51±8.82 101.63±9.32 8.32±2.10 3.41±0.71 25.72±1.21 管理后 338 133.73±13.01 81.68±8.71 6.58±1.81 2.78±0.42 22.16±1.32 t值 70.730 127.412 60.530 25.121 150.011 P值 0.003 0.002 0.004 0.004 0.002 注：1 mmHg=0.133 kPa。
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