摘要
目的:通过对慢性阻塞性肺疾病(COPD)患者的社区管理,探讨将COPD纳入基本公共卫生服务规范健康管理范畴的必要性和可行性。方法:社区医生团队在2008～2010年对172例慢性阻塞性肺疾病患者进行社区管理,包括进行上门随访,对患者症状、体征进行检查,服药情况的查询和指导,对辅助治疗和护理的指导,有针对性的实施健康促进干预等,同时征求对工作的意见和建议。结果:管理期间发现至少37.21%患者症状、体征继续存在,6.97%患者复发或症状体征加重再次入院或转上级医院;且COPD患者并发症、合并症多,病情复杂;所有服务对象对上门随访100%满意。结论:COPD的社区管理纳入基本公共卫生服务规范管理范畴,将有利于减少COPD患病率,稳定病情、保护劳动力,减轻社区与居民因病的经济负担。
Objective：By community management of COPD will be included in the basic public health services, the need for standardized health management aspects and feasibility. Method ： Team of community doctors in 2008 -2010 on 172 patients with COPD disease patients with community management, including site followup on the symptoms and signs checks, medication status inquiries and guidance to assist in the treatment and care guidance. The implementation of targeted health promotion intervention, and to seek the views of our work and recommendations. Results ： Management found that at least 37.21% during the symptoms and signs continue to exist, 6.97% of the patients symptoms and signs of increased recurrence or readmitted or transferred to a higher level hospital; and complications in patients with COPD, complications and more complex disease,all clients 100% satisfaction on - site follow - up. Conclusion： COPD in the community management of basic public health services into standard management areas, will help reduce the prevalence of COPD, stable disease, protect labor, community and residents to reduce the economic burden of illness.
