社区高血压患者自我管理干预效果评价

高血压等慢性病已成为严重危害居民健康的重要公共卫生问题,以社区为平台开展慢病防治管理势在必行.慢病自我管理方法强调患者在管理所患慢病方面的责任和潜能,是近年来国际上兴起的一项简单易行、效果明确的适合我国国情的慢病干预措施[1].本文通过引进自我管理方法开展社区示范研究,评价高血压预防干预效果,并对其措施进行初步评估,探索适合黑龙江省牡丹江市社区可持续的慢病自我管理实施机制,为推进慢病自我管理在全市社区的广泛应用提供依据.     

慢病照护模式在社区高血压前期患者的实施与评价

目的探讨慢病照护模式(CCM)对社区高血压前期患者健康管理的效果.方法 采用社区干预研究,将379例符合高血压前期诊断的患者分为干预组和对照组.干预组接受慢病照护模式管理,对照组接受常规的门诊和电话随访.干预时间1年,采用自制高血压前期危险因素评估量表(包括血压,体重指数,腰臀比,血脂等)和国际体力活动量表(IPAQ)长问卷评价干预效果. 结果干预后干预组在收缩压,体重指数,体力活动量,胆固醇,甘油三酯的变化值明显优于对照组,差异均有统计学意义(均P<0.05),而舒张压,腰臀比,高密度脂蛋白,低密度脂蛋白的变化值比较无统计学差异(P>0.05).结论 高血压前期患者应常规纳入慢病管理.其中, CCM是一种行之有效管理高血压前期患者的慢病管理模式.     

以专科护士为主导的糖尿病患者参与健康照护方案的效果评价△

目的：探讨以专科护士为主导的糖尿病患者参与健康照护方案的效果。方法：采用便利抽样方法，选取2020年9月-2021年8月在盐城市某三级甲等医院内分泌科收治的230例2型糖尿病患者为研究对象，其中2020年9月-2021年2月收治的110例患者为对照组，2021年3月-2021年8月收治的120例患者为试验组。试验组采用以专科护士为主导的糖尿病患者参与健康照护方案，对照组采取传统的健康宣教方式。比较干预前后社区联络护士的理论成绩，2组患者的入院时、出院前、出院后6个月的自我管理能力，糖化血红蛋白值以及患者再次住院率。结果：干预后社区糖尿病联络护士的理论成绩显著提升（t=-7.03，P＜0.01）；与对照组比较，试验组的3个时间点的患者自我管理能力显著提升（均P＜0.01）；试验组患者6个月后的糖化血红蛋白显著低于对照组（t=-2.502，P＜0.05）；试验组患者的再次入院率低于对照组。结论：以专科护士为主导的糖尿病患者参与健康照护方案能够提高患者参与健康照护的积极程度，提升自我管理能力，可以推广至慢病管理。     

即时通讯软件在社区慢病管理中的应用分析

目的探讨即时通讯软件在社区慢病管理中的作用。方法选取深圳某社区123名高血压或糖尿病患者作为研究对象,随机分为两组,对照组60例,观察组63例。对照组患者采用常规慢病管理措施进行干预,观察组患者再此基础上,利用即时通讯软件进行干预。对比两组患者干预后收缩压、舒张压、空腹血糖、餐后2 h血糖情况,健康知识知晓情况,自我管理效果及月平均上门随访时间。结果观察组患者收缩压、舒张压、空腹血糖、餐后2 h血糖低于对照组,差异有统计学意义(P0.05)。观察组患者健康知识知晓率、自我管理效果优于对照组,差异有统计学意义(P0.05)。观察组患者所需月平均上门随访时间少于对照组患者,差异具有显著统计学意义(P0.01)。结论即时通讯软件在社区慢病患者管理中具有积极的作用,能够有效控制慢病患者病情,增加患者自我管理能力,减少医护人员随访时间,不失为一种值得深入探索的干预模式。     

多学科协作照护模式在COPD患者家庭肺康复中的应用研究

目的:探究COPD患者家庭肺康复中应用多学科协作照护模式的临床效果。方法 :选择我院于2017年3月～2018年5月收治的288例COPD患者作为本次研究的对象,随机分成对照组(144例)和干预组(144例),对照组COPD患者给与常规性基础照护模式,干预组COPD患者在家庭肺康复中实施多学科协作照护模式,比较两组对于COPD疾病的认识程度及自我管理能力。结果 :干预组各指标均存在显著优势,P0.05。结论 :对于COPD患者,在家庭肺康复中实施多学科协作照护模式能够显著提高患者对COPD疾病的认识,提高自我管理能力,提高生活质量。     

社区高血压患者自我管理依从性及影响因素研究

随着社区慢病防治工作的深入开展,在社区高血压防治中遇到一些实际问题,尤其是社区高血压管理及健康教育有效实施的难度和高血压患者对社区防治管理措施的依从性问题,迫切需要探索有效的防治干预措施.本文对社区高血压患者的自我管理依从性进行初步评估,并对其影响因素予以分析研究,以便为探索可持续的慢病自我管理实施机制,提高社区高血压防治技能和水平提供依据.     

社区高血压病管理对患者自我管理的影响分析

目的了解泸州市社区高血压患者参与社区管理对患者自我管理的影响,为完善社区高血压病防控工作提供参考依据。方法本次调查是以社区为基础,以其中529例高血压患者为研究对象,采用多阶段抽样的方法 ,对泸州市社区35～69岁的居民进行问卷调查。结果在529例高血压患者中,有27.4%的患者参与了社区管理,其中31. 7%的患者参与规范化社区管理。高血压总自我管理的及格率为31. 3%,多元非条件Logistic回归分析发现,性别、职业、参加慢性病知识讲座对高血压患者自我管理有影响,参加社区管理对高血压患者自我管理有影响(OR=2.236, 95%CI:1.350～3.703)。结论泸州市社区高血压患者参与社区管理和患者自我管理能力情况均不理想,加强社区慢病管理有助于提高患者的自我管理能力。     

慢病照护模式在社区糖尿病患者管理中的应用

目的探讨慢病照护模式对社区糖尿病患者管理的应用效果。方法本街居委一61例患者为慢病照护模式管理组,本街居委二66例患者为对照组。对象入组一年后,使用SF36(生活质量评价量表,medical outcome short-form 36 item health survey)、CSSD70(糖尿病控制状况量表,Control Status Scale for Diabetics)和A-DQOL(糖尿病特异性生命质量测定量表,Diabetes quality of life)进行干预效果的评估。结果在糖尿病控制状况和糖尿病特异性生命质量方面,两组有统计学差异。结论慢病照护模式在社区糖尿病患者管理中应用有良好的效果。     

以需求为导向的健康教育对老年COPD患者自我管理能力的影响

目的探讨以需求为导向的健康教育对老年COPD患者知识、信念和行为水平及自我管理能力的影响。方法以老年COPD稳定期患者177例为研究对象,采取自身对照研究的方法,根据患者的健康风险评估结果,由COPD管理小组成员主要负责实施以需求为导向的健康教育,并与患者和家属共同制定自我健康管理计划并实施,跟踪随访时间为6个月。采用COPD知识、信念和行为问卷和COPD患者自我管理量表,比较以需求为导向的健康教育前后老年COPD患者的知识、信念和行为水平及自我管理能力的差异。结果干预后老年COPD患者知识、信念和行为水平和自我管理能力各维度评分显著提高(P0.05)。结论以需求为导向的健康教育可以提高老年COPD患者知识、信念和行为水平和自我管理能力,有利于患者病情的控制,也为健康教育实践和研究提供参考。     

强化中医慢病管理对慢阻肺患者知信行的影响

目的探究并明确强化中医慢病管理对慢性阻塞性肺疾病(COPD)患者知信行的影响。方法选取2018年10月-2019年10月于天津市和平区新兴街社区卫生服务中心确诊为COPD稳定期的患者80例,随机分为对照组和观察组各40例,两组患者均在治疗过程接受中医慢病管理,观察组在此基础上强化教育和指导。比较两组COPD知识、态度、行为量表评分、服药依从性评分和护理满意率。结果观察组患者的慢病管理后COPD知识、态度、行为量表各项评分高于管理前和对照组,差异有统计学意义(P<0.05);对照组的态度和行为两项评分管理前后无明显变化,差异无统计学意义(P>0.05)。随访1周,两组患者的服药依从性差异无统计学意义(P>0.05),随访4、8、12周后,观察组患者的服药依从性评分明显高于对照组,差异有统计学意义(P<0.05)。观察组患者满意率为97.5%,明显高于对照组的85.0%,差异有统计学意义(P<0.05)。结论中医慢病管理在提高COPD患者知信行和服药依从性中应用价值较高,值得临床推广应用。     

Disease-Specific Self-Management Programs in Patients with Advanced Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is a long-term illness. As the disease progresses, it become more complex and spirals into an abstract complex of interrelated physical, emotional and psychosocial problems. Patients are in a constant process of learning as they endure, manage and adapt to the changing nature of the disease. It has recently been proposed that self management should be a part of the standard care for patients with COPD.This review presents a comprehensive and critical evaluation of the international literature with respect to the benefits of disease-specific self-management programs on health status and the use of health resources in patients with advanced COPD.This review screened all English-language studies indexed in Medline that investigated patient education and self management in patients with COPD, and were published in peer-reviewed journals between 1966 and 2003. Randomized controlled trials of self management in COPD were included in this review if health status or the use of health resources were measured.A best-evidence synthesis was conducted and ten studies were selected for this review. It was found that there was extreme variation between the studies in terms of the content and intensity of self-management programs, continuum of the patient program, follow-up visits, and support provided to patients. Of the ten studies, four reported a significant improvement in health status for patients in the self-management groups compared with usual-care groups. Physician visits (acute) were significantly reduced in the self-management group compared with the usual-care group in two out of four studies in which it was assessed. Self management was also associated with a reduction in emergency room visits in one out of two studies and a reduction in hospital admissions or duration of hospitalization in one out of five studies.The findings of this review reveal new evidence that disease-specific self management can improve patients’ health status and reduce physician visits and hospital use. Self-management programs that are coupled with a supervised exercise-training program would probably be more effective in improving dimensions of health status. Programs combined with communication from a trained health professional could be integrated into standard medical practice and support full population access. However, there are still many unanswered questions that need to be addressed with respect to the specific components of effective education for patients with COPD, methods to adjust self-management programs to suit the needs of individual patients, and long-term maintenance strategies.     

Evaluating Complex Health and Social Care Program Using Multi-Criteria Decision Analysis: A Case Study of “Better Together in Amsterdam North”

ObjectivesMulti-criteria decision analysis (MCDA) has been recommended to support policy making in healthcare. However, practical applications of MCDA are sparse. One potential use for MCDA is for the evaluation of programs for complex and vulnerable patients. These complex patients benefit from integrated care programs that span healthcare and social care and aim to improve more than just health outcomes. MCDA can evaluate programs that aim to improve broader outcomes because it allows the evaluation of multiple outcomes alongside each other. In this study, we evaluate an innovative integrated care program in the Netherlands using MCDA.MethodsWe used an innovative MCDA framework with broad outcomes of health, well-being, and cost to evaluate the Better Together in Amsterdam North (BSiN) program using preferences of patients, partners, providers, payers, and policy makers in the Netherlands. BSiN provides case management support for a period of 6 months. Seven outcomes that previous research has deemed important to complex patients were measured, including physical functioning and social relationships and participation.ResultsWe find that the program improved the overall MCDA score marginally, and, thus, after 6 and after 12 months, BSiN was preferred to usual care by all stakeholders. BSiN was preferred to usual care, mostly owing to improvements in psychological well-being and social relationships and participation.ConclusionsThe integrated healthcare and social care program BSiN in the Netherlands was preferred to usual care according to an MCDA evaluation. MCDA seems a useful method to evaluate complex programs with benefits beyond health.     

COPD: Does Inpatient Education Impact Hospital Costs and Length of Stay?

Background: Chronic Obstructive Pulmonary Disease (COPD) is the third leading cause of death in the United States and costs approximately $50 billion in annual healthcare costs. Certain interventions such as COPD inpatient education programs have demonstrated effectiveness in reducing healthcare utilization and reducing healthcare associated costs.

Purpose: To assess the effectiveness of chronic obstructive pulmonary disease (COPD) inpatient education using existing respiratory therapy staff in an academic health system.

Methodology/Approach: This retrospective observational study employed a matched case-control design. Inpatients admitted with a COPD related condition in this study received self-management interventions from Registered Respiratory Therapists (RTs). The sample includes retrospective administrative and medical record data on 84 inpatients with a diagnosis of COPD admitted in 2016 through 2017. Patients received self-management interventions at the bedside by trained RTs while admitted to acute care areas, progressive care units and intermediate care units. Effectiveness of inpatient education was compared before and after the interventions. Hospitalization costs and length of stay (LOS) are the primary outcome measures.

Results: Statistical analyses revealed that inpatient COPD education appears to reduce hospital length of stay and associated costs. Post hoc regression analyses revealed that age, gender, marital status, and number of visits were significantly associated with LOS; whereas, smoking, LOS, and number of visits were significantly associated with hospitalization costs.

Practice Implications: COPD patient education may be an effective strategy at reducing hospital costs and healthcare utilization overall. Empowering patients to take responsibility for their own health outcomes by improving self-efficacy has proven to demonstrate value.     

Integrated Chronic Obstructive Pulmonary Disease Management in Primary Care

Increased attention has recently been paid to disease management programs in the primary care of chronic obstructive pulmonary disease (COPD). Key elements of these programs are reactivation, lifestyle change, and exacerbation management.It is important that the patient is actively involved in the treatment plan. After diagnosis of COPD by repeated spirometry, a tailored disease management program should be designed in collaboration with the patient. Individual points of attention could be encouraging smoking cessation, improving inhaler technique, or improving exercise tolerance. Central to disease management of COPD is multidisciplinary implementation of an exacerbation rapid action plan. Research has shown that self-management of exacerbations reduces their duration, which presents a further argument for the active involvement of the patient in developing their treatment plan.A region-wide implementation plan based on the ‘Kroonluchter’ multidisciplinary disease management plan has been initiated in Rotterdam, the Netherlands. In this program, patients enrolled in eligible primary care practices are invited to participate in a repeated pulmonary function test. Depending on their individual disease burden, patients may receive optimization of their medication by their primary care physician, a tailored 6-month specific training program with a physiotherapist, or medication compliance monitoring and repeated inhalation instruction by a pharmacist. Patients who were obese or had muscular depletion could also receive a dietary intervention with a specialized dietitian in addition to the training program. In cases where the diagnosis was uncertain or patients had very severe lung pathology, access to specialist pulmonary physicians was available at short notice. All patients who participated in the 6-month training program received an annual BODE (Body mass index, airway Obstruction, Dyspnea, Exercise capacity) index and administration of the Clinical COPD Questionnaire to assess the effectiveness of the program. Extra attention was given to following up patients immediately after an exacerbation.At present, approximately 2.8% of the total practice population is participating in the program. Almost all participants in the 6-month training program have reported perceptible and measurable improvements in exercise tolerance, and a strong collaboration has developed between primary care providers, patients, and secondary care.     

Networks, disease management programs, GP coordinator: analysis of recent ambulatory reforms in Germany

Strengthening the role of the general practitioner in the conduction and coordination of specialized, inpatient and social care to ensure the continuity is a trend observed in recent health reforms in European countries. In Germany, from the second half of the 1990s, driven by economic pressures, a specific legislation and initiatives of the providers themselves have developed new organizational structures and care models for the purpose of the integration of the health care system and the coordination of health care in the form of: physicians networks, practitioner coordinator model, diseases management programs and integrated care. From a literature review, document analysis, visits to services and interviews with key informants, this paper analyzes the dynamics of these organizational changes in the German outpatient sector. The mechanisms of integration and coordination proposed are examined, and the potential impacts on the efficiency and quality of new organizational arrangements are discussed. Also it is analyzed the reasons and interests involved that point out the obstacles to the implementation. It was observed the process of an incremental reform with a tendency of diversification of the healthcare panorama in Germany with the presence of integrated models of care and strengthening the role of general practitioners in the coordination of patient care.     

Self-Management Services

For people with chronic illness, day-to-day responsibilities for care fall most heavily on patients and their families. Organising healthcare to strengthen and support self-management in chronic illness while assuring that effective medical, preventative and health maintenance interventions take place is key to effective disease management.This paper discusses the behavioural principles and empirical evidence about healthcare designed to maximise positive patient participation in chronic disease care. Four main essential elements are key: (i) collaborative definition of problems, in which patient-defined problems are identified along with medical problems diagnosed by physicians; (ii) targeting, goal-setting and planning, where patients and providers together agree on realistic objectives and set an action plan for attaining them; (iii) availability of a continuum of self-management training and support options that teach patients the skills needed to carry out medical regimens, guide health behaviour change and provide emotional support; (iv) active and sustained follow-up during which patients are contacted at specified intervals to monitor health status and reinforce progress in meeting care plan objectives. These elements constitute a common core of services and approaches that do not need to be replicated for each chronic condition.     

A sustainable behavioral health program integrated with public health primary care.

The need for behavioral healthcare for the poor and indigent is well documented in rural North Carolina, and integrated behavioral healthcare--that is, mental health screening and treatment offered as part of primary care services--has proven a very effective and efficient method to improve patients' health. In 2000, the Buncombe County Health Center (BCHC) began a grant-funded program treating depressed patients in its public health clinics and school health programs. The Health Center used the opportunity to send a team to the Management Academy for Public Health to learn business principles that could be applied to the challenge of sustaining this program as part of its ongoing public health service delivery for the county. Using their business plan from the Management Academy, the BCHC sought funding from various stakeholders, and, through their support, was able to institute a fully integrated behavioral health program in 2004. The BCHC has now joined forces with other partners in the state to address statewide policy changes in support of such programs. These efforts are an example of how a community health center can apply entrepreneurial thinking and strategic business planning to improve healthcare and effect wide-ranging change.     

Implementing a multidisease chronic care model in primary care using people and technology.

Management of chronic disease is performed inadequately in the United States in spite of the availability of beneficial, effective therapies. Successful programs to manage patients with these diseases must overcome multiple challenges, including the recognized fragmentation and complexity of the healthcare system, misaligned incentives, a focus on acute problems, and a lack of team-based care. In many successful programs, care is provided in settings or episodes that focus on a single disease. While these programs may allow for streamlined, focused provision of care, comprehensive care for multiple diseases may be more difficult. At Intermountain Healthcare (Intermountain), a generalist model of chronic disease management was formulated to overcome the limitations associated with specialization. In the Intermountain approach, which reflects elements of the Chronic Care Model (CCM), care managers located within multipayer primary care clinics collaborate with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. An important part of the intervention is widespread use of an electronic health record (EHR). This EHR provides flexible access to clinical data, individualized decision support designed to encourage best practice for patients with a variety of diseases (including co-occurring ones), and convenient communication between providers. This generalized model is used to treat diverse patients with disparate and coexisting chronic conditions. Early results from the application of this model show improved patient outcomes and improved physician productivity. Success factors, challenges, and obstacles in implementing the model are discussed.     

Enhancing cost-effective care with a patient-centric chronic obstructive pulmonary disease program

Coronary obstructive pulmonary disease (COPD) is an escalating health problem for individuals, their families, and the public at large, resulting n considerable morbidity and mortality. A 1-year pilot program was conducted at a managed care medical group to empower COPD patients with self-management skills and improve their quality of life through enhancing cost-effective care. A total of 141 COPD patients were enrolled in the intervention group that imparted self-management principles, and provided telephonic nursing outreach and an action plan for symptom exacerbation. The same number of patients in the control group accessed care from their physician or urgently through emergency departments. At the conclusion of this program, paid claims in the intervention group were significantly (P < 0.001) decreased compared to the control group. Primary care physician visits were also significantly (P < 0.001) greater in the intervention group than in the control group. Although not statistically significant, hospital admissions, bed-days, and emergency department visits showed downward trends in the intervention group. Working with their clinical team, motivated patients can gain health benefits through self-management in an era of rising COPD prevalence and cost of care.