老年慢性心力衰竭患者出院后医院与社区协同健康管理研究

目的探讨医院、社区协同健康管理对出院后老年慢性心力衰竭（CHF）患者的影响，为建立社区老年CHF患者综合管理模式提供依据。方法纳入228例老年CHF患者为研究对象，以社区为单位将患者随机分为社区管理组（106例）与协同管理组（122例）。社区管理组出院后转社区卫生服务机构管理，医院不再提供后续健康干预治疗；协同管理组由医院、社区协同管理。1年后比较两组患者用药依从性、因心力衰竭再住院率、病死率、平均再住院天数、医疗费用及明尼苏达心力衰竭生活质量（LiHFe）评分。结果两组一般临床资料无明显差异，具有可比性。经过1年的健康管理，与社区管理组相比，协同管理组用药依从性明显提高（）（2=8．97，P〈0．05）。协同管理组再住院率、人均住院天数、住院费用与社区管理组相比均明显降低，差异有统计学意义（X^2=9．91，t=3．78、3．61，P〈0．05）。在进行健康管理前，两组患者的LiHFe评分差异无统计学意义（X^2=0．42、0．81、0．66、0．44、0．41，P〉0．05），出院1年后，协同管理组的各项评分均优于社区管理组，差异有统计学意义（t=6．37、11．81、6．16、9．64、9．／3，P〈0．05）。但两组患者的病死率差异无统计学意义（X^2=0．247，P〉0．05）。结论医院、社区协同健康管理是老年CHF患者降低再住院率、减轻医疗负担、提高生活质量切实有效的管理措施。

Hospital-community-based collaborative management in health care of elderly out-patients with chronic heart failure

Objective To explore the effect of hospital-community-based collaborative management on elderly out-patients with chronic heart failure （CHF）. Methods A total of 228 out-patients with CHF were randomly assigned to the community-based health management group （ n = 106 ） and the hospital-community-based collaborative health management group （n = 122）. In community-based health management group, the patients only received community-based health management, while in hospital-community-based collaborative health management group the patients accepted comprehensive health management. One year later, medication compliance, readmission rate, mortality, average length of hospitalization, medical costs and Minnesota living with heart failure questionnaire （LiHFe） were compared between the two groups. Results No statistically significant differences in clinical data were found between the two groups at baseline. After one year, medication compliance was significantly improved in hospital-community-based collaborative health management group when compared to community-based health management group （ X^2 = 8.97, P 〈 0. 05 ）. Readmission rate, average length of hospitalization and medical costs of hospital-community-based collaborative health management group were lower than community-based health management group （ X^2 = 9. 91 ; t = 3.78,3.61 ; all P 〈 0. 05 ）. One year ago, the items of LiHFe including physical dimension, emotion,symptom and social dimension and total score showed no significant between the two group （ t = 0. 42,0. 81,0. 66,0. 44,0. 41 ; all P 〉 0. 05 ）. While one year later, all the scores of hospital-community- based collaborative health management group were significantly declined（ t = 6. 37,11.81,6. 16,9. 64,9. 13; P 〈 0.05 ）. Mortality showed no significant difference between the two groups （ X^2 = 0. 247, P 〉 0. 05 ）. Conclusion Hospital-community-based collaborative management for health care may be a practical and valuable strategy for decreasing readmission rate and medical burden and improving quality of life of elderly patients with CHF.