目的 探讨家庭医生责任制延续性管理方式对社区老年脑卒中患者的影响.方法 选取本院2014年1月~2015年6月随访登记的100例社区老年脑卒中患者,随机分为干预组(50例)和对照组(50例),对照组采用传统的脑卒中患者管理方案,干预组实施家庭医生责任制延续护理模式,分别观察干预前后的药物与治疗的依从性、脑卒中复发危险因素以及复发率.结果 经过6个月的干预,比较两组患者的药物和治疗依从性,差异有统计学意义(P<0.05);干预组患者血压(BP)、空腹血糖(FB)、血脂、同型半胱氨酸水平(HCY)、颈动脉斑块的性质、戒烟、限酒、体质量指数(BMI)的达标率均高于对照组(P<0.05);脑卒中复发率低于对照组,差异有统计学意义(2%vs 14%,P<0.05).结论 家庭医生责任制延续性管理方式对社区老年脑卒中患者能够更好的提高患者药物与治疗的依从性,控制脑卒中复发危险因素,从而降低脑卒中患者的复发率,值得临床进一步推广.%Objective To study the transitional care from the family doctor responsibility system in community cerebral ischaemic stroke in elderly patients. Methods One-hundred patients with cerebral ischaemic stroke were randomly divided into two groups. The control group patients were treated traditionally for stroke, and the intervention group patients were treated with the transitional care of the family doctor responsibility system. The qualified rate of control of the cerebral ischaemic stroke recurrence-related risk factors was compared in the two groups to identify differences. Results After six months, in the intervention group, the qualified rates of control in the patients' drugs use, treatment compliance and cerebral ischaemic stroke recurrence-related risk factors including blood pressure (BP),fasting blood glucose (FB),blood lipids,blood uric acid,homocysteine levels (HCY),smoking cessation,drinking limitation, and body mass index(BMI)were higher than the control group(P < 0.05), with a stroke recurrence rate of 2% compared with 14% in the control group (P < 0.05). Conclusion The transitional care of the family doctor responsibility system can improve drug use, treatment compliance, and cerebral ischaemic stroke recurrence-related risk factors and decrease recurrence in community cerebral ischaemic stroke in elderly patients.
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