社区水平的多学科综合管理对脑梗死患者二级预防效果研究 Effect of Multidisciplinary Management in Community on Secondary Prevention of Cerebral Infarction

目的 研究社区水平的多学科综合管理对恢复期脑梗死患者的二级预防效果。 方法 将出院的172例脑梗死患者按照随机数字法分为管理组（90例）和对照组（82例）。管理组给 予多学科综合管理（由神经内科医师、康复师、精神科医师以及护士等共同参与对社区脑梗死患者 的管理），对照组执行出院医嘱。随访6个月。观察指标：主要指标为脑梗死复发率，其他指标有他汀 治疗率和低密度脂蛋白胆固醇达标率、抗血小板治疗率、高血压治疗率和血压控制率、糖尿病治疗 率和血糖达标率、美国国立卫生研究院卒中量表评分和中度以上残疾率、卒中后抑郁的比例、健康 教育相关知识的知晓率。 结果 两组复发率比较，差异无统计学意义。管理组在其他观察指标方面均好于对照组，比较差 异均具有统计学意义（P＜0.05）。 结论 这种多学科管理模式的关键是回社区的脑梗死患者将规范的二级预防、康复和护理方案带 给社区全科医生，专科和全科医生进行互动式管理。此管理虽未显著降低社区脑梗死患者的复发率， 但可以提高二级预防药物的依从性和各种危险因素的控制率，有利于提高二级预防的效果。 Abstract: Objective To study the effect of multidisciplinary management in community on secondary prevention in patients with cerebral infarction during recovery period. Methods A total of 172 discharged patients with cerebral infarction were randomly divided into management group (n =90) and control group (n =82). The neurologists, physical therapist, psychiatrists and nurses all got involved in multidisciplinary management of patients with cerebral infarction in community. The multidisciplinary management was performed in management group, and discharge instructions were performed in control group. The follow-up period was 6 months. The primary observation indictor was ischemic stroke recurrence, the secondary indictors included statin use, antiplatelet therapy, hypertension and diabetes treatment, the control rate of LDL-C, blood pressure and blood glucose, the NIHSS score and moderate-to-severity disability, post-stroke depression occurrence and the awareness rate of health education knowledge. Results Ischemic stroke recurrence had no significant difference between the two groups (P =0.196). The secondary indictors of the management group were all better than that of the control group (P