周礼娟 彭德荣 杨春琴 蒋云 张琳

摘 要 目的：分析家庭醫生助理实施精细化流程在社区脑卒中患者管理中的效果。方法：由信息平台自2018年2月至2019年1月抽取上海彭浦新村街道社区卫生服务中心纳入管理的脑卒中患者200例为干预对象，用随机数字表法分为研究组和对照组各100例，研究组中有男性55例，女性45例；平均年龄为（63.48±4.72）岁；对照组中有男性57例，女性43例；平均年龄为（63.83±5.11）岁。对照组患者在常规诊疗时依据医生工作站电脑提示框进行随访管理，研究组患者诊疗时依据医生工作站电脑提示框由家庭医生助理开展精细化流程管理，管理12个月后进行两组患者康复效果、自我感受负担、满意度等的评定比较。结果：管理12个月后，两组患者脑卒中生存质量（SS-QOL）、日常生活活动能力的Barthel指数（BI）、运动功能的Fugl-Meyer运动功能量表（FMA）评分均高于入组时，情感、经济、身体负担等方面的自我感受负担评分均低于入组时，差异均有统计学意义（P<0.05）；管理后研究组患者SS-QOL、BI、FMA评分高于对照组，自我感受负担评分均低于对照组，差异具有统计学意义（P<0.05），同时管理后研究组患者管理满意度高于对照组，差异具有统计学意义（P<0.05）。结论：由家庭医生助理实施精细化流程管理社区脑卒中患者可提高康复效果，缓解自我感受负担、提升患者满意度。

关键词 脑卒中；社区管理；家庭医生助理；精细化流程

中图分类号：R743 文献标志码：A 文章编号：1006-1533（2021）16-0053-05

Analysis of the effect of family doctor assistants implementing refined processes in the management of stroke patients in the community

ZHOU Lijuan1， PENG Derong1， YANG Chunqin1， JIANG Yun2， ZHANG Lin2

（1.Office of Pengpuxincun Community Health Service Center of Jingan District， Shanghai 200435， China； 2. Health Management Department of Pengpuxincun Community Health Service Center of Jingan District， Shanghai 200435， China）

ABSTRACT Objective： To analyze the effect of family doctor assistants implementing refined processes in the management of stroke patients in the community. Methods： From February 2018 to January 2019， the information platform selected 200 stroke patients included in the management of the center as the intervention objects， and divided into a research group and a control group with 100 cases each by random number table method. There were 55 males and 45 females in the research group； the average age was （63.48±4.72） years； in the control group， there were 57 males and 43 females； the average age was （63.83±5.11） years. The patients in the control group were followed up according to the computer prompt box of the doctors workstation during routine diagnosis and treatment， during the diagnosis and treatment of patients in the research group， the family doctors assistant carried out refined process management according to the computer prompt box of the doctors workstation. After 12 months of management， the evaluation and comparison of the rehabilitation effect， self-feeling burden and satisfaction of the two groups of patients were carried out. Results： After 12 months of management， the stoke specific quality of life scale（SS-QOL）， the Barthel index（BI） of the activities of daily living， and the Fugl-Meyer assessment（FMA） scores of the two groups were higher than those at the time of enrollment， self-feeling burden scores in emotion， economy， physical burden and so on were lower than those at the time of enrollment， and the differences were statistically significant（P<0.05）； after management， the scores of SS-QOL， BI， and FMA of the research group were higher than those of the control group， and the self-feeling burden scores of the research group were lower than those of the control group， and the difference was statistically significant（P<0.05）. At the same time， the management satisfaction of the research group was higher than that of the control group， and the difference was statistically significant（P<0.05）. Conclusion： The implementation of refined process management by family doctor assistants for stroke patients in the community can improve the rehabilitation effect， ease the burden of self-feeling， and improve patient satisfaction.

KEY WORDS stroke； community management； family physician assistant； refined process

脑卒中是现代人群常见的心脑血管病变之一。脑卒中后遗症期患者在诊疗中面临的主要问题是各类功能障碍的康复，而社区的康复治疗在脑卒中二级预防中发挥重要作用[1]。自2011年起上海市部分区启动了家庭医生制度试点，这是一种以家庭医生为核心，以患者管理为服务内容的新型诊疗模式。社区卫生服务中心改革是社区卫生服务体系改革中的重点内容，能够高效、有序地面对社区人数多、人口老龄化等问题，能提供优质无缝隙的健康管理服务[2-4]。……