“全-专”结合团队社区管理稳定期慢性阻塞性肺疾病的效果评价

黄双庆 潘宇峰 周敏 易碧慧 朱莉 汤文珺

摘 要 目的：评价“全-专”结合团队社区管理稳定期慢性阻塞性肺疾病（慢阻肺）的效果。方法：以2019年9月上海市宝山区淞南镇慢阻肺高危人群筛查被確诊的100例稳定期慢阻肺患者作为研究对象，采用随机数字表法分为管理组和常规组，常规组患者接受全科普通门诊基本诊疗，管理组患者与家庭医生“1+1+1”签约服务，接受“全-专”结合团队规范化（规范药物治疗和非药物治疗）管理。管理时间为12个月，观察两组患者的肺功能、呼吸症状、焦虑、生活质量等的变化情况。结果：管理12个月后，管理组的FVC值、CAT和mMRC症状评估、焦虑和生活质量评分、慢阻肺防治知识知晓率、吸入剂药物正确使用率的改善均明显优于常规组，差异均有统计学意义（P<0.05）。结论：“全-专”结合团队管理模式可改善慢阻肺的症状和生活质量，提升了基层医疗机构管理慢阻肺的能力。

关键词 慢性阻塞性肺疾病；肺功能；“全-专”结合；管理

中图分类号：R563 文献标志码：A 文章编号：1006-1533（2021）02-0059-04

*基金项目：2018年上海市“医苑新星”青年医学人才培养资助计划[沪卫计人事（2019）72号]；2019年上海市社区卫生协会社区科研项目（SWX19M07）

Evaluation of the effect of the “general practitioner-specialist” combination team in the community management of chronic obstructive pulmonary disease in stable period

HUANG Shuangqing1， PAN Yufeng2， ZHOU Min3， YI Bihui4， ZHU Li1， TANG Wenjun4（1.Department of General Practice of Songnan Community Health Service Center of Baoshan District， Shanghai 200441， China； 2.Office of Songnan Community Health Service Center of Baoshan District， Shanghai 200441， China； 3. Respiratory Department of Shanghai Ruijin Hospital， Shanghai 200025， China； 4. Department of Nursing of Songnan Community Health Service Center of Baoshan District， Shanghai 200441， China）

ABSTRACT Objective： To evaluate the effect of "general practitioner-specialist combination" team in the community management of chronic obstructive pulmonary disease（COPD） in stable period. Methods： In September 2019， 100 patients with stable COPD who were diagnosed in the high-risk population screening for COPD in Songnan Community of Baoshan District， Shanghai were selected as the research objects， and divided into a management group and a conventional group by random number table method， the patients in the conventional group received basic diagnosis and treatment in general outpatient clinics， and the patients in the management group signed "1 + 1 + 1" services with family doctors， and received standardized management of “general practitioner-specialist” combination team（standardized drug treatment and non drug treatment）. The management time was 12 months. The changes of pulmonary function， respiratory symptoms， anxiety and quality of life of the two groups were observed. Results： After 12 months of management， FVC value， CAT and mMRC symptom assessment， anxiety and quality of life score， awareness rate of COPD prevention and treatment knowledge， and correct use rate of inhalant drugs in the management group were significantly better than those in the conventional group（P<0.05）. Conclusion： The management mode of “general practitioner-specialist” combination team can improve the symptoms and quality of life of COPD， and improve the ability of primary medical institutions to manage COPD.

KEY WORDS chronic obstructive pulmonary disease； pulmonary function； general practitioner-specialist combination； management

慢性阻塞性肺疾病（慢阻肺）是一种常见的、可预防、可治疗的疾病，其特征是持续的呼吸道症状和气流受限，其原因是气道和（或）肺泡异常，通常由暴露于大量有毒颗粒物或气体引起，并受宿主因素（包括肺发育异常）的影响[1]。我国慢阻肺死亡率居各国之首，整体疾病负担已居我国疾病负担第三位[2]。我国40岁及以上人群慢阻肺患病率高达13.7%[3]，约1/3的慢阻肺患者没有症状，有相当部分患者没有得到及时的诊治[4]。……