基层医疗卫生机构应用“诊疗工具包”在慢性阻塞性肺疾病健康管理方面的研究实践

Research and Practice on the Application of “Diagnostic and Treatment Toolkits” in Chronic Obstructive Pulmonary Disease Health Management in Primary Healthcare Institutions

摘要: 研究背景及目的：慢性阻塞性肺疾病(Chronic Obstructive Pulmonary Disease, COPD)，简称慢阻肺，是我国基层社区群众中比较高发的一种慢性呼吸系统疾病，但其规范管理率普遍较低。本研究旨在通过收集分析应用“诊疗工具包”进行管理的慢阻肺病人的相关数据，建立“评估–回顾–调整”的随访管理流程，加强对COPD患者的病情监察及管理，为今后开展基层COPD防治管理水平提升工作提供循证医学依据，使COPD患者取得长期获益，改善患者的生活质量及存活率，减少急性发病次数，降低住院率及均次住院费用等。方法：本研究通过在山东省青岛市黄岛区泊里镇社区卫生服务中心覆盖的29个村医团队中推广应用包含筛查、诊断、治疗、评估和健康教育模块的工具包，对基层医务人员进行培训，采用随机抽样法对符合入组要求的105名慢阻肺患者实施自2024年5月至2025年5月为期1年的健康管理。将入组慢阻肺患者分为对照组与干预组，对照组只进行随访，干预组按照制定好的COPD诊疗工具包对患者进行相关指导，获取参与研究患者的各项数据信息，后对获取的信息进行分析汇总，运用统计学方法评估运用工具包进行管理是否对慢阻肺患者的疾病进程管理有一定的临床应用价值。结果：经统计学方法分析获得干预组患者的改良版英国医学研究委员会呼吸困难量表(Modified Medical Research Council Dyspnea Scale，mMRC量表)评分结果及慢性阻塞性肺疾病患者自我测试(Chronic Obstructive Pulmonary Disease Assessment Test, CAT)评分较对照组有明显改善，差异有统计学意义(p < 0.05)。而两组患者中性别、年龄、FEV1、住院费用、住院频次因素未见明显统计学差异(p > 0.05)。另外，干预组患者的SpO₂%值较该患者应用工具包管理前有所改善，但改善幅度不大，未见明显统计学差异(p > 0.05)。结论：通过应用工具包对COPD患者进行系统管理，改善了患者的疾病控制状况，提高了患者对病情的自我管理能力，改善了患者的症状评分等指标。结论表明，推广应用慢阻肺诊疗工具包是提升基层慢阻肺健康管理水平的有效可行策略。

Abstract: Background and Objectives: Chronic Obstructive Pulmonary Disease (COPD) is a highly prevalent chronic respiratory disease among residents in primary communities in China, yet its standardized management rate remains generally low. This study aims to establish a follow-up management process of “Assessment-Review-Adjustment” by collecting and analyzing relevant data of COPD patients managed using the “Diagnostic and Treatment Toolkit”. It seeks to strengthen the monitoring and management of COPD patients’ conditions, provide evidence-based support for future efforts to improve primary COPD prevention and management, enable long-term benefits for COPD patients, enhance their quality of life and survival rate, reduce the number of acute exacerbations, and lower hospitalization rates and average hospitalization costs. Methods: This study promoted the application of a toolkit containing screening, diagnosis, treatment, assessment, and health education modules among 29 village doctor teams under the Boli Town Community Health Service Center in Huangdao District, Qingdao City, Shandong Province. Primary medical staff were trained, and 105 COPD patients meeting the inclusion criteria were randomly selected to receive one-year health management from May 2024 to May 2025. Participants were divided into a control group and an intervention group. The control group only received follow-up visits, while the intervention group received guidance based on the developed COPD Diagnostic and Treatment Toolkit. Data from all participants were collected, analyzed, and summarized. Statistical methods were used to evaluate whether toolkit-based management had clinical value in controlling the disease progression of COPD patients. Results: Statistical analysis showed that the Modified Medical Research Council Dyspnea Scale (mMRC) scores and Chronic Obstructive Pulmonary Disease Assessment Test (CAT) scores of patients in the intervention group were significantly improved compared with the control group (p < 0.05). No significant statistical differences were observed between the two groups in terms of gender, age, FEV1, hospitalization costs, or hospitalization frequency (p > 0.05). Additionally, the SpO₂% values of patients in the intervention group improved slightly compared with before the toolkit application, but the improvement was not statistically significant (p > 0.05). Conclusions: Systematic management of COPD patients using the toolkit improved their disease control status, enhanced their self-management abilities, and led to better symptom scores and other indicators. The results indicate that promoting the application of the COPD Diagnostic and Treatment Toolkit is an effective and feasible strategy to improve the level of primary COPD health management.