基于“全科-专科”分级诊疗构建心脑协防共管的房颤社区管理模式及现状研究

戴慧敏; 卜军; 姜萌; 唐岚; 朱敏; 张胜冰; 应小盈

doi:10.16766/j.cnki.issn.1674-4152.004215

基于“全科-专科”分级诊疗构建心脑协防共管的房颤社区管理模式及现状研究

doi: 10.16766/j.cnki.issn.1674-4152.004215

戴慧敏¹,
卜军²,
姜萌²,
唐岚¹,
朱敏¹,
张胜冰¹,
应小盈^2, ,

1.
上海市浦东新区潍坊社区卫生服务中心，上海 200122
2.
上海交通大学医学院附属仁济医院心内科，上海 200127

基金项目:

上海市浦东新区卫生系统学科带头人培养计划 PWRd2022-06

上海市加强公共卫生体系建设三年行动计划重点学科建设项目 GWVI-11.1-26

详细信息

通讯作者:
应小盈，E-mail：9116@renji.com

中图分类号: R541.75 R197.61
计量
- 文章访问数: 2
- HTML全文浏览量: 1
- PDF下载量: 0
- 被引次数: 0
出版历程
- 收稿日期: 2024-10-29

Theory and implementation of general-specialty hierarchical heart-brain co-prevention and co-management mode for atrial fibrillation

1.
Pudong New District Weifang Community Health Service Center, Shanghai 200122, China

摘要

摘要: 目的随着人口老龄化的日趋严重和分级诊疗政策的不断推进，为有效提升社区心房颤动(简称房颤)-脑卒中高危老年人群的管理能力，预防脑卒中发生，旨在探索“全科-专科”心脑协防共管的房颤社区综合管理模式。方法上海市潍坊社区卫生服务中心与上海交通大学附属仁济医院基于上海市“1+1+1”签约分级诊疗模式，联合建立了“全科-专科”心脑协防共管的房颤社区综合管理模式。该模式依托设立在社区的“仁济-潍坊”心房颤动-心源性脑卒中专病工作室，通过信息化手段首先建立房颤患者电子健康档案，其次制定房颤的分级诊疗标准和转诊流程，最后实现药品和实验室检查的同质化，从而构建一级预防(预防疾病)-优质全专诊疗(同质化诊疗)-二级预防(慢病管理)-心脏和脑病康复(高质量生活)的全生命周期健康管理体系。结果初步实施情况：专病门诊共管理房颤患者27例，房颤患者的抗凝率为59.25%，远高于前期调研的抗凝基线率(28.10%)。结论通过“全科-专科”心脑协防共管，一方面实现了优质医疗资源适当下沉，提升全科医生诊疗能力，简洁高效识别疾病严重程度；另一方面，设立专职助理员规范患者抗凝监测和连续性管理，提升患者自我管理依从性，形成了急慢分治、上下联动的分级诊疗模式，并提升了社区房颤管理的整体效果。
- 心房颤动 /
- 分级诊疗 /
- 家庭医生签约 /
- 全科医学 /
- 心脑协防共管
Abstract: Objective With the aging of the population and continuous promotion of the implementation of the hierarchical medical system, to effectively enhance the management ability of the high-risk elderly population for atrial fibrillation(AF)-stroke in the community and prevent stroke occurrence, actively explore the "general-specialty" hierarchical heart-brain co-prevention and co-management mode for AF. Methods Weifang Community Health Service Center (WCHSC) and Renji Hospital, Shanghai Jiaotong University School of Medicine (RHSJUSM), developed a "general-specialty" hierarchical and collaborative management model based on the "1+1+1" hierarchical contractual service delivery mode implemented in Shanghai. The model relies on the establishment of the Renji-Weifang AF and Cardioembolic Stroke Specialty Clinic within the community. The model first establishes electronic health records for AF patients, then determines grading diagnosis, treatment standards, and referral processes, and finally standardizes drug and laboratory test management using information technology. This approach creates a full lifecycle health management model encompassing primary prevention (disease prevention), high-quality full-specialty diagnosis and treatment (homogenized care), secondary prevention (chronic disease management), and rehabilitation for heart and brain diseases (high-quality life). Results A total of 27 AF patients were managed. The anticoagulation rate of AF patients was 59.25%, which was much higher than the baseline anticoagulation rate of 28.10% in the previous survey. Conclusion It highlights how the model facilitates the appropriate allocation of high-quality medical resources to primary healthcare institutions, improves GPs' diagnostic and therapeutic abilities, and simplifies the identification of disease severity. Additionally, with the support of a full-time assistant for anticoagulant monitoring and ongoing self-management, patient compliance is enhanced, and finally improves the overall effectiveness of community AF management. This mode supports the formation of a hierarchical diagnosis and treatment system characterized by separate management of acute and chronic conditions and collaboration between higher and lower healthcare institutions.
- Atrial fibrillation /
- Hierarchical medical treatment /
- Contracted family doctor services /
- General practice /
- Heart-brain co-prevention and co-management
利益冲突 无

HTML全文

图 1 房颤-心源性脑卒中“全科-专科”分级诊疗协作管理标准和流程

Figure 1. Criteria and workflow for a general-specialty hierarchical management mode in AF-related cardioembolic stroke

下载: 全尺寸图片幻灯片

参考文献(24)

[1]	国家卫生健康委办公厅. 国家卫生健康委办公厅关于印发中国脑卒中防治指导规范(2021年版)的通知[EB/OL]. (2021-08-27)[2024-10-24]. https://www.nhc.gov.cn/yzygj/c100068/202108/682b5a958a7443b2b8269ab9303cfbeb.shtml. Office of the National Health Commission Notice of the General Office of the National Health Commission on Printing and Distributing the Guidelines for the Prevention and Treatment of Stroke in China (2021 Edition[EB/OL]. (2021-08-27)[2024-10-24]. https://www.nhc.gov.cn/yzygj/c100068/202108/682b5a958a7443b2b8269ab9303cfbeb.shtml.
[2]	中华医学会心血管病学分会, 中国生物医学工程学会心律分会. 心房颤动诊断和治疗中国指南[J]. 中华心血管病杂志, 2023, 51(6): 572-618. Cardiovascular Disease Branch of Chinese Medical Association, Cardiac Rhythm Branch of Chinese Society of Biomedical Engineering. Chinese Guidelines for the Diagnosis and Treatment of Atrial Fibrillation[J]. Chinese Journal of Cardiovascular Diseases, 2023, 51(6): 572-618.
[3]	金晖, 杨东辉. 中外心房颤动流行病学特点比较[J]. 心血管病学进展, 2024, 45(7): 622-626. JIN H, YANG D H, Comparison of Epidemiological Characteristics of Atrial Fibrillation in China and Foreign Countries[J]. Advances in Cardiovascular Diseases, 2024, 45(7): 622-626.
[4]	上海市民政局. 2023年上海市老年人口、老龄事业和养老服务工作综合统计信息发布[EB/OL]. (2024-07-06)[2024-10-24]. https://mzj.sh.gov.cn/2024bsmz/20240706/73924c349f4d475a9d46b6019f1a396b.html. The 2023 comprehensive statistical information on Shanghai' s elderly population, aging affairs, and elderly care services work[EB/OL]. (2024-07-06)[2024-10-24]. https://mzj.sh.gov.cn/2024bsmz/20240706/73924c349f4d475a9d46b6019f1a396b.html.
[5]	王丹沁. 上海民革建言完善农村养老服务体系: 资源整合模式创新[EB/OL]. (2024-01-23)[2024-10-24]. https://www.sh.chinanews.com.cn/shms/2024-01-23/120807.shtml. WANG Q D. Shanghai Revolutionary Committee of the Chinese Kuomintang suggests Improving the Rural Elderly Care Service System: Innovation in Resource Integration Models[EB/OL]. (2024-01-23)[2024-10-24]. https://www.sh.chinanews.com.cn/shms/2024-01-23/120807.shtml.
[6]	DI CARLO A, BELLINO L, CONSOLI D, et al. Prevalence of atrial fibrillation in the Italian elderly population and projections from 2020 to 2060 for Italy and the European Union: the FAI project[J]. Europace, 2019, 21(10): 1468-1475. doi: 10.1093/europace/euz141
[7]	赵继宗. 我国脑心血管共患疾病现状与临床研究[J]. 首都医科大学学报, 2022, 43(5): 671-673. ZAHO J Z, Current status and clinical research of brain-heart comorbid vascular diseases in China[J]. J Capital Med Univ, 2022, 43(5): 671-673.
[8]	林春忠, 赵亮, 王朝昕, 等. 基于数据挖掘的县级医院房颤患者抗凝治疗现状及影响因素研究[J]. 中华全科医学, 2021, 19(11): 1951-1955. doi: 10.16766/j.cnki.issn.1674-4152.002209 LIN C Z, ZHAO L, WANG C X, et al. Current situation and influencing factors of anticoagulant therapy for patients with atrial fibrillation in county hospitals based on data mining[J]. Chinese Journal of General Practice, 2021, 19(11): 1951-1955. doi: 10.16766/j.cnki.issn.1674-4152.002209
[9]	闫珊, 沈慧, 顾智淳, 等. 新型智慧化管理模式在心房颤动患者社区随访管理中的效果评价[J]. 中华全科医学, 2024, 22(6): 1008-1012. doi: 10.16766/j.cnki.issn.1674-4152.003555 YAN S, SHENG H, GU Z C, et al. Evaluation of the effect of a new intelligent management model in community follow-up management of patients with atrial fibrillation[J]. Chinese Journal of General Practice, 2024, 22(6): 1008-1012. doi: 10.16766/j.cnki.issn.1674-4152.003555
[10]	HINDRICKS G, POTPARA T, DAGRES N, et al. 2020 ESC guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS)[J]. Eur Heart J, 2021, 42(5): 373-498. doi: 10.1093/eurheartj/ehaa612
[11]	戴慧敏, 卜军, 张芳, 等. 慢性心力衰竭"全科-专科"分级诊疗协作管理模式及开展现状研究[J]. 中国全科医学, 2020, 23(7): 779-783. DAI H M, BO J, ZHANG F, et al. Theory and Implementation of General-specialty Hierarchical Management Mode for Chronic Heart Failure[J]. Chinese Journal of General Practice, 2020, 23(7): 779-783.
[12]	国家中医药管理局. 关于印发心房颤动分级诊疗技术方案的通知[EB/OL]. (2019-09-17)[2024-10-24]. http://www.natcm.gov.cn/bangongshi/zhengcewenjian/2019-09-17/10905.html. National Administration of Traditional Chinese Medicine (NATCM) Notice on Issuing the Technical Plan for Hierarchical Diagnosis and Treatment of Atrial Fibrillation[EB/OL]. (2019-09-17)[2024-10-24]. http://www.natcm.gov.cn/bangongshi/zhengcewenjian/2019-09-17/10905.html.
[13]	顾泳. 市卫生健康委负责人介绍社区卫生服务网络建设家庭医生签约率今年目标39% 有条件的社区可开展适宜技术外科手术[EB/OL]. (2023-04-14)[2024-10-24]. https://www.shanghai.gov.cn/nw4411/20230414/6fafe3837b614083ac5f84e665174afc.html. GU Y. The head of the municipal health commission introduced the construction of the community healthcare service network. This year, the target for the family doctor contract rate is set at 39%[EB/OL]. (2023-04-14)[2024-10-24]. https://www.shanghai.gov.cn/nw4411/20230414/6fafe3837b614083ac5f84e665174afc.html.
[14]	上海: 越来越多居民信赖家庭医生, 超950万人签约[EB/OL]. (2023-05-18)[2024-10-24]. https://new.qq.com/rain/a/20230518A097IM00. Shanghai: growing trust in family doctors with over 9.5 million residents signed up[EB/OL]. (2023-05-18)[2024-10-24]. https://new.qq.com/rain/a/20230518A097IM00.
[15]	郭海英, 曾辉. 社区心房颤动的综合管理[J]. 中国循证心血管医学杂志, 2023, 15(5): 638-640. GUO H Y, ZENG H, Integrated Care Model for Community Patients with Atrial Fibrillation[J]. Chinese Journal of Evidence-Based Cardiovascular Medicine, 2023, 15(5): 638-640.
[16]	汤志杰, 孙国珍, 王洁, 等. 早期心房颤动筛查的成本效果分析研究进展[J]. 中国全科医学, 2023, 26(1): 104-112, 117. TANG Z J, SUN G Z, WANG J, et al. Cost-effectiveness Analysis of Early Screening for Atrial Fibrillation: a Review of Recent Advances[J]. Chinese Journal of General Practice, 2023, 26(1): 104-112, 117.
[17]	KHURSHID S, HEALEY J S, MCLNTYRE W F, et al. Population-based screening for atrial fibrillation[J]. Circ Res, 2020, 127(1): 143-154. doi: 10.1161/CIRCRESAHA.120.316341
[18]	ADELEKE Y, MATTHEW D, PORTER B, et al. Improving the quality of care for patients with or at risk of atrial fibrillation: an improvement initiative in UK general practices[J]. Open Heart, 2019, 6(2): e001086. DOI: 10.1136/openhrt-2019-001086.
[19]	SIEBENHOFER A, ULRICH L R, MERGENTHAL K, et al. Primary care management for patients receiving long-term antithrombotic treatment: a cluster-randomized controlled trial[J]. PLoS One, 2019, 14(1): e0209366. DOI: 10.1371/journal.pone.0209366.
[20]	VAN DEN DRIES C J, VAN DOORN S, RUTTEN F H, et al. Integrated management of atrial fibrillation in primary care: results of the ALL-IN cluster randomized trial[J]. Eur Heart J, 2020, 41(30): 2836-2844. doi: 10.1093/eurheartj/ehaa055
[21]	杨荣, 刘长明, 廖晓阳, 等. 三级综合医院联合社区医院开展心房颤动综合管理协同路径的探索与思考[J]. 中国全科医学, 2021, 24(1): 36-39. YANG R, LIU C M, LIAO X Y, et al. Refection on the Collaborative and Integrated Management Pathway for Atrial Fibrillation by a Large Tertiary General Hospital and a Community Hospital[J]. Chinese Journal of General Practice, 2021, 24(1): 36-39.
[22]	刘露, 刘晓宇. 全科医生在心房颤动综合管理中的作用[J]. 中华全科医学, 2021, 19(9): 1553-1556. doi: 10.16766/j.cnki.issn.1674-4152.002110 LIU L, LIU X Y, Role of general practitioners in the integrated management of atrial fibrillation[J]. Chinese Journal of General Practice, 2021, 19(9): 1553-1556. doi: 10.16766/j.cnki.issn.1674-4152.002110
[23]	徐佶佶, 陆志仁, 倪衡如, 等. 社区全科医生心房颤动诊疗能力调查及继续教育的提升效果[J]. 心血管康复医学杂志, 2022, 31(1): 37-42. XU J J, LU Z R, NING H R, Investigation on diagnostic and therapeutic ability of community general practitioners for atrial fibrilla-tion and improvement effect of continuing education[J]. Chinese Journal of Cardiocascular Rehabilitation Medicine, 2022, 31(1): 37-42.
[24]	李波, 尹红, 姚峰, 等. 基层医务人员对心房颤动疾病的认知情况调查分析[J]. 中国心脏起搏与心电生理杂志, 2021, 35(1): 41-43. LI B, YING H, YAO F, et al. Investigation and analysis about atrial fibrillation related knowledge for grassroots medical staff[J]. Chinese Journal of Cardiac Pacing and Electrophysiology, 2021, 35(1): 41-43.