本文選題：社區(qū)全科醫(yī)生簽約 + 血脂異常��； 參考：《浙江大學(xué)》2017年碩士論文

【摘要】：目的:探索基于社區(qū)醫(yī)養(yǎng)護(hù)一體化簽約血脂異常分層綜合管理模式,評(píng)價(jià)該模式對(duì)血脂異�；颊叩墓芾硇Ч�。方法:本文采用隊(duì)列研究,選取杭州市某街道社區(qū)居民2586例,篩查出血脂異常居民774人,其中簽訂杭州市醫(yī)養(yǎng)護(hù)一體化簽約服務(wù)協(xié)議的居民406人,未簽約居民368人,再?gòu)闹蟹謩e共隨機(jī)抽取420例血脂異�；颊咦鳛檠芯繉�(duì)象,其中簽訂協(xié)議者220例納入干預(yù)組,未簽訂協(xié)議者200例納入對(duì)照組。干預(yù)組由全科醫(yī)生團(tuán)隊(duì)進(jìn)行一對(duì)一簽約,以問(wèn)卷的形式收集研究對(duì)象的相關(guān)信息,由社區(qū)護(hù)士建立健康檔案和慢性病檔案,并進(jìn)行為期12個(gè)月的團(tuán)隊(duì)分層綜合管理。首先根據(jù)分層管理辦法,由全科醫(yī)生團(tuán)隊(duì)管理,如管理期3個(gè)月內(nèi)隨訪不達(dá)標(biāo),則轉(zhuǎn)診到血脂異常防治首席醫(yī)生團(tuán)隊(duì)處。由首席醫(yī)生和首席護(hù)士進(jìn)行個(gè)性化指導(dǎo)和診療方案調(diào)整,繼續(xù)進(jìn)行3個(gè)月隨訪,達(dá)標(biāo)者轉(zhuǎn)回到原全科醫(yī)生團(tuán)隊(duì)進(jìn)行管理,不達(dá)標(biāo)者轉(zhuǎn)診到心血管專科診療,由心血管專科醫(yī)生調(diào)整治療方案,同時(shí)全科醫(yī)生團(tuán)隊(duì)追蹤隨訪。對(duì)照組建立個(gè)人健康檔案,保持原有的社區(qū)治療管理模式,即全科醫(yī)生藥物治療,社區(qū)護(hù)士健康宣教和定期隨訪。12個(gè)月的管理期結(jié)束后,采用SPSS 19.0軟件,使用非條件多因logistic回歸分析法,分析干預(yù)組和對(duì)照組的服藥依從性,不良生活方式改變,血脂相關(guān)指標(biāo)(TC、LDL-C、TG、HDL-C、FBG及UA),組內(nèi)高TC血癥、高TG血癥、高LDL-C血癥、低HDL-C血癥、超重/肥胖、腹型肥胖、高血壓、高尿酸血癥、高血糖等的比率,組內(nèi)干預(yù)前后中高危人群的比率等,探索社區(qū)醫(yī)養(yǎng)護(hù)一體化簽約服務(wù)下團(tuán)隊(duì)分層綜合管理對(duì)血脂異�；颊叩男Ч�。結(jié)果:血脂異常患者管理12個(gè)月后,干預(yù)組服藥依從性明顯提高,服藥率增加,差異有統(tǒng)計(jì)學(xué)意義(P＜0.05);干預(yù)組的不良生活方式改變率高于對(duì)照組,干預(yù)組的TC、LDL-C、TG、FBG及UA下降比率和HDL-C升高比率也高于對(duì)照組,差異均有統(tǒng)計(jì)學(xué)意義(P0.05)。干預(yù)組的高TC血癥、高TG血癥、高LDL-C血癥、低HDL-C血癥、超重/肥胖、腹型肥胖、高血壓、高尿酸血癥患者下降比率,中高危人群下降比率,均高于對(duì)照組,差異有統(tǒng)計(jì)學(xué)意義(P0.05),而兩組間的高血糖率變化差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論:醫(yī)養(yǎng)護(hù)一體化簽約服務(wù)下團(tuán)隊(duì)分層綜合管理,明顯提高了血脂異�；颊叩姆幰缽男�,更有效的改變了患者的不良生活方式,減少了代謝異常發(fā)生率,降低了中高危人群比率,從而有效提高了血脂異�；颊叩墓芾硇Ч�。
[Abstract]:Objective: to explore the stratified and integrated management model of dyslipidemia based on community medicine and maintenance, and to evaluate the effect of this model on patients with dyslipidemia. Methods: a cohort study was conducted to select 2586 residents of a street community in Hangzhou, and 774 residents with dyslipidemia were screened out. A total of 420 patients with dyslipidemia were randomly selected from the study group, of which 220 were included in the intervention group and 200 in the control group. The intervention group was contracted one-to-one by the team of general practitioners. The relevant information of the subjects was collected by questionnaire, and the health and chronic disease files were established by community nurses, and the team was managed by stratified and integrated management for 12 months. Firstly, according to the hierarchical management method, the general practitioner team manages, if the management period is not up to the standard within 3 months, then referred to the chief doctor team for the prevention and treatment of dyslipidemia. By the chief doctor and chief nurse to carry on the individuation instruction and the diagnosis and treatment plan adjustment, continue to carry on the follow-up for 3 months, the person who meets the standard returns to the original general practitioner team for management, the person who does not meet the standard is referred to the cardiovascular specialized diagnosis and treatment, The regimen was adjusted by cardiovascular specialists and followed up by a team of general practitioners. In the control group, the individual health records were established, and the original management model of community treatment was maintained, that is, drug therapy by general practitioners, health education by community nurses and regular follow-up. After 12 months of management, SPSS 19.0 software was used. Non-conditional multifactorial logistic regression analysis was used to analyze the drug compliance, the changes of poor lifestyle, the related indexes of blood lipids, hyperTC, hypertriglyceridemia, high LDL-C, low HDL-C, overweight / obesity in the intervention group and control group. The rates of abdominal obesity, hypertension, hyperuricemia, hyperglycemia, and the ratio of high risk group before and after intervention were explored to explore the effect of group stratification and comprehensive management on patients with dyslipidemia under the integrated contract service of community medicine and maintenance. Results: after 12 months of management, the compliance and the rate of medication in the intervention group increased significantly (P < 0.05), and the change rate of the bad lifestyle in the intervention group was higher than that in the control group. In the intervention group, the decrease rate of TCU LDL-CU FBG and UA and the increase rate of HDL-C were also higher than those in the control group, and the difference was statistically significant (P 0.05). The decreasing rates of hyperTC, hypertriglyceridemia, hyper, low HDL-C, overweight / obesity, abdominal obesity, hypertension and hyperuricemia in the intervention group were higher than those in the control group. The difference was statistically significant (P 0.05), but there was no significant difference in hyperglycemia between the two groups (P 0.05). Conclusion: under the service of integrated medical service and maintenance, the group management can obviously improve the compliance of patients with dyslipidemia, change their bad lifestyle more effectively, and reduce the incidence of abnormal metabolism. Reduce the ratio of high-risk population, thus effectively improve the management of patients with dyslipidemia.
【學(xué)位授予單位】：浙江大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R473.2
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本文編號(hào)：1821471