县域内紧密型医共体分级诊疗模式对中-重度COPD患者救治的影响

doi:10.3760/cma.j.issn.1007-1245.2024.18.021

摘要/Abstract

摘要：

目的　探讨县域内紧密型医共体分级诊疗模式对中-重度慢性阻塞性肺疾病（COPD）患者救治的影响。方法　选取2022年5月至2023年4月本县域内医共体的基层中心分院和牵头医院（连州市人民医院）接诊的中-重度COPD患者150例设为研究组，同时选取2021年5月至2022年4月接诊的150例中-重度COPD患者设为对照组。对照组男120例，女30例，年龄（67.25±7.63）岁，严重程度C级60例、D级90例；研究组男123例，女27例，年龄（66.83±7.55）岁，严重程度C级56例、D级94例。研究组予以县域内紧密型医共体分级诊疗模式管理，对照组予以常规诊疗模式管理。随访1年后比较两组患者依从性，病死率，第1秒用力呼气容积（FEV₁%），COPD患者自我评估测试（CAT）评分，6 min步行距离，1年急性加重次数及生活质量等。采用t检验、χ²检验。结果　研究组病死率为3.33%（5/150），低于对照组的病死率9.33%（14/150），差异有统计学意义（χ²=7.545，P=0.006）；研究组失访25例（16.67%），对照组失访16例（10.67%）；对照组和研究组实际成功随访各120例。研究组COPD患者的复诊率、戒烟率、吸入剂使用率分别为81.67%（98/120）、79.17%（95/120）、92.50%（111/120），高于对照组的30.00%（36/120）、28.33%（34/120）、59.17%（71/120），差异均有统计学意义（均P<0.05）。随访1年后，与对照组相比，研究组FEV₁%较高［（44.97±6.16）%比（37.16±5.24）%］，1年急性加重次数较少且CAT评分较低［（1.20±0.45）次比（1.90±0.55）次，（17.75±5.35）分比（22.10±5.05）分］，6 min步行距离较长［（263.28±93.06）m比（177.65±95.12）m］，1年医疗费用较低［（12 071.25±390.63）元比（13 519.94±386.75）元］，差异均有统计学意义（均P<0.05）；研究组生活质量各维度评分均较对照组高（均P<0.001）。结论　县域内紧密型医共体分级诊疗模式有助于减缓中-重度COPD患者肺功能的进一步恶化，减少每年急性发作的频率，降低患者的住院费用及病死率，提高患者的生活耐受能力，改善预后，值得临床进一步研究应用。

关键词:

慢性阻塞性肺疾病, 急性加重期, 县域内紧密型医共体, 分级诊疗模式

Abstract:

Objective　To explore the impact of hierarchical diagnosis and treatment model of compact county medical community on the treatment for patients with moderate to severe chronic obstructive pulmonary disease (COPD). Methods　A total of 150 patients with moderate to severe COPD who were admitted to the grassroots central branch of the medical community and the leading hospital of our country (Lianzhou People's Hospital) from May 2022 to April 2023 were selected as a study group, and 150 patients with moderate to severe COPD from May 2021 to April 2022 were selected as a control group. In the control group, there were 120 males and 30 females, aged (67.25±7.63) years, with 60 cases of grade C and 90 cases of grade D. In the study group, there were 123 males and 27 females, aged (66.83±7.55) years, with 56 cases of grade C and 94 cases of grade D. The study group was managed by the hierarchical diagnosis and treatment model of compact county medical community, while the control group was managed by the routine diagnosis and treatment model. After 1 year of follow-up, the compliance, mortality, forced expiratory volume in the first second (FEV₁%), COPD Assessment Test (CAT) score, 6-min walking distance, annual acute exacerbation times, and quality of life were compared between the two groups. t test and χ² test were used. Results　The mortality rate of the study group was 3.33% (5/150), which was lower than that of the control group [9.33% (14/150)], with a statistically significant difference (χ²=7.545, P=0.006). There were 25 cases (16.67%) lost to follow-up in the study group and 16 cases (10.67%) in the control group. The control group and the study group were followed up successfully with 120 cases each. The follow-up rate, smoking cessation rate, and inhaler usage rate in the study group were 81.67% (98/120), 79.17% (95/120), and 92.50% (111/120), which were higher than those in the control group [30.00% (36/120), 28.33% (34/120), and 59.17% (71/120)], with statistically significant differences (all P<0.05). After 1 year of follow-up, compared with the control group, the FEV₁% of the study group was higher [(44.97±6.16) % vs. (37.16±5.24) %], the number of acute exacerbations and CAT score were lower [(1.20±0.45) vs. (1.90±0.55), (17.75±5.35) points vs. (22.10±5.05) points], the 6-min walking distance was longer [(263.28±93.06) m vs. (177.65±95.12) m], and the annual medical expenses were lower [(12 071.25±390.63) yuan vs. (13 519.94±386.75) yuan], with statistically significant differences (all P<0.05); the quality of life scores of the study group were higher than those of the control group (all P<0.001). Conclusion　The hierarchical diagnosis and treatment model of compact county medical community is helpful to slow down the further deterioration of lung function in patients with moderate to severe COPD, reduce the number of acute exacerbations, reduce the annual medical expenses and mortality rate, and improve the patients' living tolerance and prognosis, which is worthy of promotion and application.

Key words:

Chronic obstructive pulmonary disease, Acute exacerbation, Compact county medical community, Hierarchical diagnosis and treatment model

万军白英连李培根黄华邵伟萍汪明星邓虹.

县域内紧密型医共体分级诊疗模式对中-重度COPD患者救治的影响 [J]. 国际医药卫生导报, 2024, 30(18): 3089-3093.

Wan Jun, Bai Yinglian, Li Peigen, Huang Hua, Shao Weiping, Wang Mingxing, Deng Hong.

Effect of hierarchical diagnosis and treatment model of compact county medical community on the treatment for patients with moderate to severe COPD [J]. International Medicine and Health Guidance News, 2024, 30(18): 3089-3093.

参考文献

[1] 曹新西,徐晨婕,侯亚冰,等.1990-2025年我国高发慢性病的流行趋势及预测[J].中国慢性病预防与控制,2020,28(1):14-19. DOI:10.16386/j.cjpccd.issn.1004-6194. 2020.01.004.
[2] Labaki WW, Rosenberg SR. Chronic obstructive pulmonary disease[J]. Ann Intern Med, 2020, 173(3):ITC17-ITC32. DOI: 10.7326/AITC202008040.
[3] 申永春,陈磊,文富强.2019年慢性阻塞性肺疾病全球创议更新要点[J].中华医学杂志,2018,98(48):3913-3916. DOI:10.3760/cma.j.issn.0376-2491.2018.48.001.
[4] 卢敏贞,高兴林.2020年慢性阻塞性肺疾病全球倡议更新解读[J].临床药物治疗杂志,2021,19(1):17-21. DOI:10.3969/j.issn.1672-3384.2021.01.004.
[5] 刘岚,王旭明,李锦波,等.云南省农村三个民族慢性阻塞性肺疾病的患病、知晓、治疗率和疾病负担[J].中华疾病控制杂志,2022,26(3):351-356. DOI:10.16462/j.cnki.zhjbkz. 2022.03.019.
[6] 中华医学会呼吸病学分会慢性阻塞性肺疾病学组.慢性阻塞性肺疾病诊治指南(2013年修订版)[J].中华结核和呼吸杂志,2013,36(4):255-264. DOI:10.3760/cma.j.issn.1001- 0939.2013.04.007.
[7] 曹文君,郭颖,平卫伟,等.HPLP-Ⅱ健康促进生活方式量表中文版的研制及其性能测试[J].中华疾病控制杂志,2016,20(3):286-289. DOI:10.16462/j.cnki.zhjbkz.2016.03.018.
[8] 荣健,戈艳红,陈贵梅,等.2010-2019年中国40岁及以上成人慢性阻塞性肺疾病患病率的Meta分析[J].现代预防医学,2020,47(13):2305-2309,2336.
[9] Adeloye D, Song P, Zhu Y, et al. Global, regional, and national prevalence of, and risk factors for, chronic obstructive pulmonary disease (COPD) in 2019: a systematic review and modelling analysis[J]. Lancet Respir Med, 2022, 10(5):447-458. DOI: 10.1016/S2213-2600(21)00511-7.
[10] 李香荷,罗青,唐娜,等.1990～2019年中国慢性阻塞性肺疾病死亡负担及变化情况分析[J].中国循环杂志,2023,38(6):681-686. DOI:10.3969/j.issn.1000-3614.2023.06.011.
[11] Valipour A, Shah PL, Pison C, et al. Safety and dose study of targeted lung denervation in moderate/severe COPD patients[J]. Respiration, 2019, 98(4):329-339. DOI: 10.1159/000500463.
[12] 董汉禹,王珺,蔡成森,等.慢性阻塞性肺疾病早期预防对策[J].实用心脑肺血管病杂志,2023,31(10):6-11. DOI:10.12114/j.issn.1008-5971.2023.00.265.
[13] 门诊慢性阻塞性肺疾病急性加重识别调研协助专家组.中国呼吸科医生对门诊慢性阻塞性肺疾病急性加重的认知及管理现状调研[J].国际呼吸杂志,2024,44(4):397-404. DOI:10.3760/cma.j.cn131368-20230718-00020.
[14] 李薇,黄可,唐星瑶,等."幸福呼吸"项目地区慢性阻塞性肺疾病高危人群筛查现状分析[J].中华健康管理学杂志,2022,16(2):77-82. DOI:10.3760/cma.j.cn115624-20210503- 00239.
[15] 白毅,施晓坤,蒋德雄,等.平昌县农村地区慢阻肺流行病学特征及相关因素分析[J].实用预防医学,2023,30(10):1239-1242. DOI:10.3969/j.issn.1006-3110.2023.10.020.
[16] 陈丽君,刘美芳,张慧芳,等.银川市≥40岁人群慢性阻塞性肺疾病流行病学数据更新及启示[J].中华健康管理学杂志,2023,17(12):893-898. DOI:10.3760/cma.j.cn115624- 20230901-00111.
[17] 李岱,郑国平,陈丽娜,等.依托医共体防治慢性阻塞性肺病策略研究[J].绍兴文理学院学报,2020,40(2):110-114. DOI:10.16169/j.issn.1008-293x.k.2020.02.018.
[18] 韩胜昔,李超红,潘常青,等.学科项目型医联体下肺癌闭环式管理的实践探索[J].中国医院管理,2019,39(12):11-12.
[19] 王海和,简钢,雷攀.某县域医共体试点建设回顾性调查分析与思考[J].中国卫生质量管理,2021,28(8):91-94. DOI:10.13912/j.cnki.chqm.2021.28.8.24.
[20] 王思琦.基于紧密型县域医共体山西模式的乡镇医疗服务数字赋能研究[D].太原:山西医科大学,2021.
[21] 汤军华,徐则兰.医联体分级诊疗模式对慢性阻塞性肺疾病患者规范化管理的影响[J].浙江临床医学,2022,24(5):739-741.
[22] 申红娟,崔兆涵,史二敏,等.紧密型医共体推动县域医疗卫生高质量发展案例研究[J].中国医院管理,2022,42(5):16-20. DOI:10.12114/j.issn.1007-9572.2022.0061.
[23] 刘杨,王凯,肖革新,等."全科医学+"紧密型医共体下慢性病管理模式构建研究:基于国际慢性病管理模式和经验[J].中国全科医学,2022,25(16):1923-1928.