目的 研究医联体模式下脑卒中高危人群筛查和干预的社区管理及效果评价.方法 2015年1～12月以北京市大兴区德茂社区和红星楼社区作为研究基地,入选200例41～91岁脑卒中高危人员,以社区为基本单元,采用随机分组方法将其分为干预组(100例)和对照组(100例).采用医联体模式下的三级综合医院对两个社区11名医生进行标准化脑卒中高危人群筛查和干预试点项目培训,医生参与干预组的随访管理.对照组不进行任何干预.主要随访指标包括社区医生对脑卒中高危人群筛查和干预项目内容的知晓率、筛查阳性率、规范化治疗接受程度;患者的脑卒中危险因素知晓率、服药率、规范化药物使用率、自我日常生活管理能力.结果 标准化脑卒中高危人群筛查和干预试点项目培训后,社区医生脑卒中高危人群筛查和干预项目内容的知晓率、筛查阳性率、规范化治疗接受程度均较培训前增高(均P＜ 0.05).干预组有效随访患者96例,对照组有效随访患者97例,随访时间为(18.5±0.5)个月.干预组患者的脑卒中危险因素知晓率、服药率、规范化药物使用率、自我日常生活管理能力均高于对照组(均P＜ 0.05).结论 通过医联体模式的三级综合医院指导下脑卒中高危人群筛查和干预的社区管理模式,提高了社区医生对脑卒中高危人群筛查和干预诊治进展及社区疾病管理控制方案的知晓率及执行度,提高了患者对脑卒中高危因素的认知率及疾病自我管理能力,改善了患者服药率和遵医行为,为医疗卫生改革探索出了新经验.%Objective To study the community management of screening and intervention of high-risk population of stroke under the guidance of medical partnerships and evaluate its effectiveness.Methods From January to December 2015,Demao Community and Hongxing Building Community in Daxing District of Beijing were selected as study bases.200 cases with high-risk of stroke aged 41-91 were collected,and randomly divided into the intervention group (100 patients) and the control group (100 patients).11 doctors from the two communities had been trained for standard of high-risk population of stroke screening and intervention pilot project in a tertiary general hospital that under the medical partnerships system.Patients in the intervention group were given follow-up management,patients in the control group were given no intervention.The main follow-up indicators for community doctors included awareness rate of screening and intervention in high-risk population of stroke,positive rate of screening,acceptance degree of standardized treatment;for patients included awareness rate of risk factors of stroke,medication rate,use rate of standardized drugs,self-daily life management rate.Results After standard training of high-risk population of stroke screening and pilot intervention,the awareness rate of community doctors on screening and intervention in high-risk population,the screening positive rate and the acceptance degree of standardized treatment were raised than before (P ＜ 0.05).In the intervention group 96 cases had effective follow-up,and in the control group 97 cases had effective follow-up,the follow-up time was (18.5±0.5) months.The awareness rate of stroke risk factors,medication rate,rate of accepting standardized drugs and self-daily life management rate in the intervention group were higher than those in the control group (P ＜0.05).Conclusion The community management model of screening and intervention in high risk population of stroke under the guidance of a tertiary general hospital that enrolled in medical partnerships system,improves the diagnosis and treatment levels of community doctors which in turn can be beneficial to recognizing and well-management of high-risk population,as well as the awareness rate and execution degree of management control program of community disease.It also improves the awareness rate and self-management level of patients with high risk factors,which contribute to patients' medication rate and nedical compliance,thus provides a new method for medical and health reform.
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