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目的评价以小区为基础的心血管病个案管理模式实施效果。方法观察对象为≥40岁心脏血管科拿慢性病处方的忠诚病人。由个案管理师负责,依管理流程,给予运动、用药与饮食宣教与提醒,6个月后检测踝臂指数(ABI)和脉搏波传导速度(PWV),询问生活质量,填写身心健康调查SF-12量表,分析结果。结果研究对象120人,男85人,女35人,平均66.8岁;6个月个案管理追踪与卫生宣教后,平均BMI 27.8,没有运动组的BMI值较高;男性抽烟率高;ABI>0.9,臂踝PWV>1 400;生理健康得45.8分,心理健康得51.9分。结论心梗与脑卒中的预防需准确预测其风险。本研究认为,ABI仪器测量为简易、安全的预测性工具;因评估时间较短,宣教成效不明显,但参与者生理健康高于国际均值;建立个案健康管理系统,可提升医疗质量与对医院的信任度与满意度。
Objective To evaluate the effect of community-based CVD case management. Methods The observation object was a loyal patient who was admitted to the Department of Cardiology of Chronic Obstetrics at age 40 years or older. Responsible for case management division, according to the management process, giving sports, medication and diet education and reminders, 6 months after the detection of ankle brachial index (ABI) and pulse wave velocity (PWV), asked about the quality of life, fill in physical and mental health survey SF- 12 scale, analyze the result. Results A total of 120 subjects were enrolled, including 85 males and 35 females, with an average age of 66.8 years. The average BMI was 27.8 after 6 months of follow-up of case management and health education. The BMI values of no exercise group were higher. , Ankle and ankle PWV> 1 400; physical health 45.8 points, mental health 51.9 points. Conclusions The prevention of MI and stroke need to accurately predict the risk. In this study, ABI instrument measurement is a simple, safe and predictive tool; because of the short assessment time, the effectiveness of mission education is not obvious, but the physical health of participants is higher than the international mean; the establishment of a case health management system can improve the quality of medical care and the hospital Trust and satisfaction.