非酒精性脂肪肝病患者社区流程化管理效果评价

目的运用项目流程化管理对非酒精性脂肪肝（NAFLD）患者进行健康管理，通过患者自我管理能力、药物治疗依从性及复诊行为是否提高，相关健康指标的改善情况，评价社区项目流程化管理的效果，探索适宜的社区NAFLD干预模式。方法随机选取非酒精性脂肪性肝病人50例，采用项目流程化管理方法，开展非酒精性脂肪肝病人的社区管理，该项目分为启动、计划、执行、控制和关闭五个过程，管理全过程实施健康干预，评价管理前后患者自我管理能力、药物治疗依从性及复诊行为改变情况，并分别在管理3个月、管理6个月和管理1年后评价实施管理后相关健康指标的改善情况。结果管理1年后病人主动控制热量摄入、合理膳食结构、主动控制体重、良好生活习惯、坚持有氧运动及戒酒人数明显增多（P〈0．01），坚持药物治疗及定期复诊行为明显提高（P〈0．01）。管理3个月后病人的体重指数、血胆固醇和空腹血糖检查结果存在差异（P〈0．05），管理6个月后病人的腰围、血甘油三酯、血压和B超检查结果存在差异（P〈0．05）。结论运用项目流程化管理进行NAFLD病人的社区管理．提高了患者的自我管理能力、药物治疗依从性、复诊行为及治疗效果。

Effectiveness Evaluation of Non-alcoholic Fatty Liver Disease Community Process Management

OBJECTIVE Application of processed management of items in health management for patients with non-alcoholic fatty liver disease（NAFLD） through the self-management of patients, drug treatment compliance and referral behavior whether to raise, to improve the situation of related health indicators, evaluation of processed management of items effect, exploration of community intervention model for NAFLD. METHODS Random selection of non-alcoholic fatty liver patients in 50 cases, using the processed management of items method, development of nonalcoholic fatty liver disease patients in community management project, the project is divided into 5processes start, plan, implementation, control and close, The implementation of health intervention in the whole process of management, evaluation of management and self-management of patients, drug therapy compliance and referral behavior change, to improve the situation and evaluation index related to health management in a year after the administration of 3 months, 6 months, and 1 year. RESULTS 1 year later the patient management active control calorie intake, reasonable diet structure, active control weight, good living habits, adhere to aerobic exercise and alcohol significantly increased the number （P〈0.01）, Adhere to drug treatment and regular follow behavior improved obviously （P〈0.01）, Differences in management and 3 months after the patient＇s body mass index, blood cholesterol, fasting blood glucose test resuhs（P〈0.05）, Differences in management after 6 months the patient waist circumference, triglyceride, blood pressure, B ultrasound examination resuhs（P〈0.05）. CONCLUSION Community management using project management for NAFLD patients, improve the patient＇s ability of self management, medication compliance, referral behavior and the effect of treatment