上海市浦东新区周浦医联体经皮冠状动脉介入治疗术后下转社区随访体系的构建与实践

目的:构建医联体经皮冠状动脉介入治疗(Percutaneous coronary intervention,PCI)术后下转社区随访体系,落实社区卫生服务中心签约服务工作,提高PCI术后患者生活质量.方法:通过浦东新区周浦社区卫生服务中心"上海市大数据家庭医生费用管理系统"采集研究数据,经规范化随访管理1年,利用生活质...

The Construction and Practice of the Community Follow-up System after Percutaneous coronary intervention,in Zhoupu Medical Consortium

OBJECTIVE To construct a follow-up system for community follow-up after percutaneous coronary intervention,(PCI),to implement contracted services by community health service centers,to improve the quality of life of patients after PCI.METHODS Purchasing the“Shanghai Big Data Family Doctor Expense Management System”project through the center,and after standardized follow-up management for 1 year,the quality of life of patients was assessed using the Quality of Life Scale SF-36 and the SAQ Seattle Angina Scale,and medication compliance was investigated.The coronary heart disease self-management scale CSMS was used to evaluate the postoperative?self-management behavior of patients.RESULTS After one year of follow-up,the quality of life scale SF-36 and the SAQ Seattle Angina Pectoris Scale showed that the patient’s quality of life was significantly improved compared with that after the operation.The CSMS evaluation results?of the coronary heart disease self-management scale showed good self-management behavior after?the operation.The completion rate was 98%,and patient satisfaction with follow-up was 89.3%.CONCLUSION The community follow-up system after PCI was successfully constructed.The follow-up team could improve the self-management awareness of patients,promote the quality of life of patients,reduce the occurrence of adverse cardiac events,and improve patient satisfaction.