心力衰竭专病信息化平台的建设及应用

目的本研究旨在探讨信息化平台在心力衰竭(以下简称"心衰")专病中的应用价值。方法依据临床需要构建包含用户管理、患者管理、随访管理、数据管理和系统管理5个模块的信息平台, 依托平台建立质控体系, 实现慢性心衰的管理, 利用数据库资料转化为临床成果。结果构建的专病信息化平台连续入组3 000余例心衰患者, 采用智能信息化手段完成部分心衰患者的长期管理, 获得了质量较高的心衰数据并实现成果转化。结论通过专病信息平台可以实现慢性心衰患者的院后长期管理, 获得高质量的循证医学证据, 为心衰领域提供预后评价系统、完善药物及手术治疗方案、综合管理体系提供理论依据和数据支持。     

慢性心力衰竭患者症状群的研究进展

慢性心力衰竭是各种心脏疾病的严重和终末阶段,由于心脏结构或功能异常导致心室充盈或射血能力受损,心排血量不能满足机体需求,因此慢性心衰患者普遍经历多种症状。慢性心衰是一种慢性、自发进展性疾病,很难根治。慢性心衰患者因多重症状困扰所致生活质量低下是其病程中需应对的首要问题。慢性心衰患者的"症状群"研究是症状管理的新视角。与单个症状的管理相比,对症状群进行管理可以提高症状管理的效率,节约医疗成本。在我国,慢性心衰患者症状群的研究尚处于探索与萌芽阶段。因此,本文将综述慢性心衰患者症状群的定义、发生机制及评估方法,以期为国内慢性心衰患者的症状管理提供循证依据。     

构建基于移动互联网的患者赋能型心衰健康管理平台

目的构建基于移动互联网的患者赋能型心衰健康管理平台,促进心衰患者进行自我管理,改善临床结局。方法开展课题研究型品管圈活动,搜集高质量临床证据,构建患者赋能型心衰健康管理平台,通过平台推广与应用,对心衰患者行为进行干预。结果平台应用后,医护人员心衰知识水平显著提升,心衰患者自我护理能力明显提升,患者再入院率、死亡率明显下降,应用效果良好。结论基于移动互联网的患者赋能型心衰健康管理平台是心衰慢性病管理的有效手段。     

双向联动疾病管理模式在社区慢性心衰高危人群中的应用及效果评价

目的探讨双向联动疾病管理模式在社区慢性心力衰竭高危人群中的应用效果。方法从高行健康体检中心筛检出240例心衰高危病例,采用随机数字法分为干预组和对照组。干预组由高行社区和上级医院组建的多学科联合管理团队对心衰高危人群按照双向联动疾病管理模式干预,对照组由不参与本研究的全科团队按照社区常规慢性病管理模式进行随访和干预指导,及时做好随访记录,2年后进行效果评价。结果两组干预前后在疾病知识、日常生活管理、依从性和生活质量方面均有很大程度的提高(P0.05),且干预后干预组显著高于对照组,差异均有统计学意义(P0.01)。两组的心衰新发例数比较差异无统计学意义(P0.05)。结论医院-社区双向联动管理模式可以提高患者对疾病的认知率、对家庭医生的依从性和日常自我管理能力,改善患者生活质量,有效减少心衰B期、C期和D期的新发病例数,为心衰高危人群的早期干预提供新思路,为社区慢性病管理提供参考依据。     

成都地区社区医生慢性心衰管理模式研究

目的增强社区医务人员在心衰患者防治管理中的作用,探讨符合成都社区医疗特点的医务人员管理心衰管理模式。方法入选新都、苏坡社区的符合研究条件的社区医务人员进行集中培训/远程指导/临床指导。每月1次,内容为心衰相关知识。观察时间为3年,观察心衰问卷合格率、医生的临床实践水平、患者的依从性和患者的满意度等指标。结果 55名社区医务人员接受了培训,培训前后问卷合格率明显增加(27.27%和80.00%,P0.05)、社区医生的临床实践水平:社区医生诊断心衰正确率(51.28%和87.18%,P0.05)、β受体阻滞剂使用率(13.74%和56.14%,P0.05)、β受体阻滞剂靶剂量的使用率(3.71%和16.88%,P0.05)、血管紧张素转换酶抑制剂(ACEI)使用率(17.55%和52.24%,P0.05)、靶剂量的使用率(5.26%和20.677%,P0.05)均明显提高。社区患者的依从性(10.45和20.33,P0.05)和满意度(41.20%和96.49%,P0.05)也明显提高。结论对社区医生进行慢性心衰疾病管理培训可显著提高社区医务人员的心衰相关知识和临床处理心衰能力,也可提高慢性心衰患者对社区医生的依从性和满意度。集中培训/远程指导/临床指导的培训方式,具有可操作性,可作为成都地区社区医生慢性心衰管理的培训方式。     

PICCO监测急性心衰患者的临床应用和护理

报告了45例心衰患者应用脉搏指示连续心排血量监测(PICCO)的护理。观察心衰心排血量、氧耗量、胸腔内血容量等指标,分析心衰患者症状改善情况.PICCO技术可充分评估心衰患者血流动力学变化,对指导心衰患者的液体管理有积极作用,技术准入管理、详细掌握患者病情、规范操作方法、细致护理观察、及时处理并发症等是应用PICCO成功的保证。     

综合营养评估工具在心衰患者中的应用价值

目的 对心衰患者所采用的综合营养评估工具及应用价值进行综述，为我国心衰患者的营养相关研究提供理论基础。方法 以“营养”、“心力衰竭”、“nutrition”、“heart failure”等为关键词，查询PubMed、Web of Science、知网等数据库相关文献，综述材料。结果 对心衰患者运用的综合营养评估工具种类较多，各量表信效度较高，营养风险和营养不良检出率较好，但均为普适量表，测评内容不能与心衰患者的临床特征完全相符，开发针对心衰患者的营养评估工具处于起步阶段。结论 综合营养评估工具对心衰患者的营养评估效果较好，未来需要加强针对心衰患者营养量表的研究。     

心衰患者血清NT-proBNP水平的检测临床意义分析

目的:分析心衰患者血清NT-pro BNP水平监测临床意义。方法:选取我院2016年7月至2016年12月收治的38例心衰患者为本次实验参与者,心衰患者采用胶体金免疫层析法(GICA)检测血清NT-pro BNP水平,比较不同心功能分期心衰患者血清NT-pro BNP水平,并探究血清NT-pro BNP水平与心衰患者预后影响。结果:心衰患者血清NT-pro BNP水平明显高于正常水平,且心衰患者心功能越低血清NT-pro BNP含量越高,心衰患者有10例再次入院,有3例出现心源性猝死。结论:对于心衰患者进行血清NTpro BNP检测能有效衡量患者心功能状态,为心衰患者临床诊疗提供重要的参考依据。     

家庭-社区-医院一体化管理对慢性心衰患者照顾者支持性需求的质性研究

目的探讨对慢性心衰患者进行家庭-社区-医院一体化管理的效果。方法回顾性分析2018年6月—2019年6月内,选择62例在该院收治的慢性心衰患者,随机抽取各31例设为研究和对照两组,用家庭-社区-医院一体化管理的为研究组,用常规管理的为对照组,比较两组患者的生活质量以及SF-36评分。结果研究组的生活质量以及SF-36评分均比对照组优(P<0.05)。结论对慢性心衰患者进行家庭-社区-医院一体化管理,可以改善患者的生活质量,提高患者生理、心理以及社会功能,确保患者更好的生活,因此具有推广的价值。     

动态心电图和动态血压监测在原发性高血压病患者中的应用研究

目的探讨动态心电图和动态血压应用于监测原发性高血压病患者的临床效果,为原发性高血压病的临床诊治提供借鉴和参考。方法选取2010年12月—2015年1月收治的原发性高血压病患者78例作为研究对象,根据患者是否合并心力衰竭(心衰)分为心衰组55例和无心衰组57例,对两组患者的动态心电图和动态血压情况进行观察和比较。计量资料采用t检验,P0.05为差异有统计学意义。结果无心衰组患者的SBP水平为(159.45±14.33)mm Hg(1 mm Hg=0.133 kPa),显著低于心衰组的(178.45±9.45)mm Hg,差异有统计学意义(P0.05)。无心衰组患者的R波振幅综合(∑R)、QTC和V1导联P波终末电势(P wave terminal force of V1,PTF-V1)水平分别为(124.35±18.34)mV(0.412±0.011)s、(0.023±0.015)mm·s,均显著低于心衰组的(132.87±8.93)mV(0.435±0.022)s、(0.055±0.016)、、mm·s,差异均有统计学意义(均P0.05)。结论动态心电图和动态血压监测可用于判断原发性高血压病患者的病情,对患者合并心衰情况进行鉴别,为患者的临床诊治提供参考借鉴。     

Research set-up concerning the effectiveness of heart failure clinics in the Netherlands

In the Netherlands, the number of patients with heart failure is increasing. Several heart failure management programs have been initiated to reduce the number of readmissions and to improve the quality of care for these patients. However, conclusive data have yet to be provided. In the 'Coordinating study evaluating outcomes of advising and counselling in heart failure', started in 16 Dutch hospitals, 1050 heart failure patients have been randomised into 3 arms: (a) care as usual, (b) care as usual + basic education and support, and (c) care as usual + intensive education and support. Patients will be recruited in 18 months with an 18 month follow-up. This study has three outcomes, namely, time to first major event (heart failure hospitalizations and death), quality of life, and costs.     

Palliation of heart failure

Heart failure is the major cause of morbidity and mortality in the United States. Stage D heart failure has a greater mortality rate than many cancers and has equivalent symptom burden and severity. There has been a paradigm shift in our understanding of the pathophysiology of heart failure. Progressive heart failure is associated with ventricular remodeling and a maladaptive neurohumoral response. Drug classes have evolved that curtail ventricular remodeling, and blunt neurohumoral responses reduce morbidity and mortality. Despite combination drug and device therapies, the management of Stage D heart failure includes palliation. Both cardiology and palliative specialists need to learn from one another in order to palliate these highly symptomatic patients. Such collaboration will enhance care and are the basis for well-conceived research trials.     

Preventive care in heart failure

The heart failure is a common, costly, disabling and fatal cardiac disorder with high mortality and a continuously growing health problem in the population. The goals of the comprehensive non-pharmacological and pharmacological care programs focus on the decrease of mortality, prevention, improve the quality of life, reducing the hospital readmissions and decreasing costs. The management approach of heart failure as a chronic illness spanning the home, outpatient and inpatient settings involve multidisciplinary team care. Nurses can play an important role in any form of care. The organization of care may be different, closely adapted to the needs of patient population and the financial resources of health care. The new strategy includes measures aiming individual care for patients at high risk of developing left-ventricular dysfunction to reduce the impact of heart failure on public and individual health. Author reported the comprehensive management program of specialized heart failure outpatient clinic in Gottsegen Gy?rgy Hungarian Institute of Cardiology.     

慢性心力衰竭社区综合管理的探讨

目的探讨慢性心力衰竭社区综合管理模式对于降低心衰的发病率,改善患者生活质量,降低家庭和社会的经济负担的作用。方法选择慢性心力衰竭患者82例,随机分为2组,综合管理组除予以病因治疗及抗心衰药物治疗外,增加积极社区综合干预措施;对照组只给予病因及抗心衰治疗。随访观察12个月。结果综合管理组在治疗12个月后心功能、生活质量、住院天数、医药费用改善情况均明显优于对照组(p<0.05)。结论社区综合管理是治疗慢性心力衰竭的有效方法,能有效改善心功能,提高生活质量,降低医疗费用,值得推广。     

Managing heart failure in primary care: first steps in implementing the National Service Framework

BACKGROUND: Heart failure is common, causes considerable morbidity, and imposes a major financial burden on both society and the National Health Service. The National Service Framework (NSF) for Coronary Heart Disease (CHD) set national standards for the management of people with heart failure in England. We examined how patients with heart failure were investigated and treated compared with NSF standards, and explored the current constraints in improving the care of these patients. METHODS: This study was carried out in two general practices (total list size 19,600) in south London. Using a computer search strategy, patients with possible heart failure were identified and clinical data extracted from their medical records. Workshops on heart failure were held at a national conference on disease management in primary care, and key stakeholders were interviewed to identify constraints in improving management. RESULTS: Ninety patients with heart failure were identified through the computerized search. Seventy-eight patients (87 per cent) had a Read code for heart failure on their electronic medical record. Forty-eight (53 per cent) patients were men and 10 (12 per cent) were aged less than 65 years. Forty-nine per cent of patients had undergone an electrocardiogram and 42 per cent an echocardiogram. Angiotensin-converting enzyme (ACE) inhibitors were prescribed to 54 per cent of patients. In the workshops and stakeholder interviews, healthcare professionals and managers reported difficulties in implementing the NSF. They expressed concerns regarding the difficulties in confirming a diagnosis of heart failure, including access to echocardiograms, prescribing ACE inhibitors among older patients, and the additional workload and resources needed to ensure they met the NSF standards for heart failure. CONCLUSION: The accurate identification of heart failure patients and recording of clinical information as part of disease registers needs to improve if primary care teams are to meet the NSF standards. There is also scope to improve the investigation and treatment of heart failure patients in primary care. Achieving these objectives will require additional resources.     

医院与社区联合健康教育对慢性心力衰竭患者的作用

目的医院与社区结合对慢性心力衰竭患者进行健康教育,探索进行健康教育后慢性心力衰竭患者生活质量、服药依从性、心力衰竭再住院率等方面的作用。方法选择出院的慢性心力衰竭患者1263例,随机分为二组：医院与社区联合组630例,社区组633例,所有病例平均随访12±1．6个月。结果医院与社区联合组患者的低盐饮食、适当运动、戒烟、服药依从性、LVEF、生活质量均明显高于管理前和社区组,差异均有统计学意义（均P〈0．05）;再住院率、平均住院日较社区组分别减少19．48％、4．98天,均有显著性差异（P〈0．05）。结论通过医院与社区联合对院外慢性心力衰竭患者进行健康教育管理,可改变生活方式,显著提高患者的生活质量、服药依从性,降低再住院率和平均住院日。     

The business concept of leader pricing as applied to heart failure disease management.

The implementation of a disease management approach for patients with heart failure has been promoted as a way to improve outcomes, including a decrease in hospitalizations. However, in the absence of rigorous cost analyses and with revenues limited by professional fees, heart failure disease management programs may appear to operate at a loss. The literature outlining the importance of disease management for patients with heart failure is summarized. We review the limitations of current cost analyses and outline the economic concepts of leader pricing, vertical integration and transaction costs to argue that heart failure disease management programs may provide significant "downstream" revenue for an integrated system of health care delivery in a fee-for-service payment structure, while reducing overall costs of care. Pilot data from a university-based program are used in support of this argument. In addition, the favorable impact on patient satisfaction and loyalty can enhance market share, a vital consideration for all health systems. Options for improving the reputation of heart failure disease management within a health system are suggested. Viewed as a loss leader, disease management provides not only quality care for patients with heart failure but also appears to provide financial benefits to the health system that funds the infrastructure and administration of the program. The actual magnitude of this benefit and the degree to which it mitigates overall administration costs requires further study.     

冠心病合并慢性心力衰竭患者不同结局的零膨胀联合脆弱模型

  目的  建立零膨胀联合脆弱模型探讨冠状动脉粥样硬化性心脏病(简称冠心病)合并慢性心力衰竭患者不同结局的影响因素,降低患者不良结局的发生。  方法  选取2014-2015年两所三级甲等医院冠心病合并慢性心力衰竭患者,收集患者住院期间的电子病历信息以及随访信息,建立零膨胀联合脆弱模型进行影响因素分析。  结果  本研究共纳入患者2 221例,1 312例患者未发生任何事件(59.07%),699例患者再住院(31.47%),307例患者死亡(13.82%)。性别、职业、BMI是冠心病合并慢性心力衰竭患者不同结局的共同影响因素,陈旧性心肌梗死、QRS间期延长是减少患者未再住院的可能性的影响因素;高龄、美国纽约心脏病协会(New York heart association, NYHA)心功能分级≥Ⅲ级、心脏瓣膜病是患者再住院与死亡的危险因素,增加再住院与死亡风险;QRS间期延长和心房颤动是患者死亡的危险因素,冠脉搭桥为保护性因素,降低患者死亡风险。  结论  零膨胀联合脆弱模型可同时分析冠心病合并慢性心力衰竭患者未再住院、再住院及死亡的影响因素,为高危患者识别、干预和治疗提供理论依据。