社区慢性心力衰竭患者疾病管理需求分析

目的调查分析成都地区社区心力衰竭患者对疾病管理的需求现状，以便提出更为行之有效的心力衰竭患者干预模式。方法2010年7—12月，以成都市青羊区苏坡社区和周边新都区城东社区两个区域作为调查基地，采用整群抽样方法对其中12个自然居民小区153例NewYork心功能分级Ⅱ-Ⅳ级心力衰竭患者通过问卷调查方式进行横断面调查。同期对该两个区域的社区医院医生22人进行心力衰竭疾病管理问卷调查。结果社区心力衰竭患者86．27％愿意采纳亲朋好友的建议，有22．22％的患者选择听从专业人员意见。约1／3患者愿意花钱请专业人员协助疾病管理，约1／3患者愿意接受免费服务。90．19％患者选择社区医务人员或专科医生对自己疾病进行管理。37．91％患者选择电话随访，23．53％患者选择面对面服务。46．41％患者选择1月随访1次。患者关注的疾病管理知识方面：43．40％的患者关注病因，24．83％的患者关注治疗，28．10％患者关注药物治疗，仅18．30％患者关注日常生活注意事项。社区医生90．91％希望采用电话随访来管理患者，68．18％的社区医生选择1月随访1次。社区医生约90％以上选择病因及药物、治疗，31．82％选择关注日常生活注意事项。结论目前成都地区社区心力衰竭患者的疾病管理协助治疗的需求不高，针对其进行干预，将有助于提高患者治疗依从性与疾病管理效果。

Demand analysis of the disease management of chronic heart failure patients in community

Objective To investigate and analyze the disease management demand status of the community chronic heart failure patients in Chengdu, in order to the more effective intervention models for these patients. Methods Cluster sampling method was used to investigate the heart failure patients（New York Heart Function Ⅱ- Ⅳ ） in two communities in Ghengdu. All the patients（total 153 numbers） received questionnaire survey. Meanwhile, the doctors in community hospitals（total 22 numbers） received questionnaire survey. Results The patients were 86.27% willing to take relations and friend# advices and 22.22% accept doctors＇ advices. About I/3 patients would like to pay for disease management, another 1/3 patients would prefer to free of charge. 90.19% patients chose the doctors in community hospitals or professional doctors for disease management, 37.91% opted telephone follow-up, and 23.53% chose face-to face service. 46.41% in them would prefer to follow-up one time in one month. The knowledge of heart disease that patients paid attention to were etiology（43.40%）, treatment（24.83%）,and drug（28.10%）, yet only 18.30% patients cared for matters needing attention in daily life. Community doctors would like to follow-up one time in one month（68.18%） by telephone（90.91%）. They Cared about the knowledge of etiology, treatment and drug（above 90%）, only 31.82% cared for matters needing attention in daily life. Conclusion Our survey showed a low level demand for the disease management of heart failure patients in Chengdu community, more intervention for these patients will increase the compliance of treatment and the effect of the disease management.