目的：探讨出院后健康管理跟踪干预对社区COPD患者康复的影响。方法：将60例COPD患者按出院时间顺序分组，单号为研究组，双号为对照组，各30例。对照组实施自我管理模式，研究组实施健康管理跟踪干预模式，干预时间为12个月。干预前后分别采用呼吸问卷（ SGRQ）和健康问卷（ SF-36）评定两组康复效果。结果：干预前，研究组SGRQ和SF-36评分与对照组比较差异无统计学意义（P>0.05）；干预后，研究组SGRQ和SF-36评分与对照组比较差异均有统计学意义（P<0.05）。结论：出院后健康管理跟踪干预能够促进社区COPD患者的良好康复，对稳定病情、改善健康状况具有积极作用。%Objective:To investigate the effect of health management tracking intervention after discharge on rehabilitation of the pa-tients with COPD in community. Methods:60 COPD patients were divided into the study group and the control group( 30 cases in each group)according to the order of discharge. The self-management model was used in the control group and the health management tracking intervention was adopted in the study group. The intervention lasted for 12 months. SGRQ and SF-36 were used to assess the rehabilitation effect of the patients in the two groups before and after the intervention. Results:There were no statistically significant differences in the comparison of the scores of SGRQ and SF-36 between the two groups before the intervention(P>0. 05);the differences in the compari-son of the scores of SGRQ and SF-36 between the two groups were statistically significant after the intervention(P<0. 05). Conclusion:The health management tracking intervention after discharge can promote the better rehabilitation of COPD patients in community and it has a positive effect on stabilizing patientˊs condition and improving their health status.
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