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目的:通过对COPD稳定期患者进行综合干预及系统管理,提高了COPD患者的知晓率、治疗率和控制率,探讨COPD的社区管理模式。方法:以健康档案为基础,对乌鲁木齐天山区碱泉街社区COPD稳定期患者进行一年的综合性干预及系统管理,包括健康教育课程培训、营养支持指导、长期随访等。干预管理前、后均进行问卷调查。结果:该项研究进行一年后,COPD相关知识(危险因素、并发症、诊断标准)的知晓率较前分别提高了18.5%、28.1%、28.9%,戒烟、合理运动、规律用药的依从性较前分别提高了29.2%、57.1%、25.6%。以COPD评估为基础,A组较康复前人数增加12.1%,B、C、D组较康复前减少分别为7.2%、3.5%、1.6%。结论:通过对COPD稳定期患者进行综合干预管理,减轻临床症状、降低发病风险,提高了生活质量。为新疆COPD的社区管理及干预提供依据。
OBJECTIVE: To improve the awareness rate, treatment rate and control rate of COPD patients by comprehensive intervention and systematic management of patients with stable COPD, and to explore the community management mode of COPD. Methods: On the basis of health records, comprehensive intervention and systematic management of patients with stable COPD in Alkalin Street community in Tianshan District, Urumqi, including health education course, nutrition support and long-term follow-up were conducted. Intervention management before and after the questionnaire. Results: One year after the study, the awareness of COPD-related knowledge (risk factors, complications, diagnostic criteria) were 18.5%, 28.1%, 28.9% higher than before, respectively. Smoking cessation, physical activity, compliance with regular medication Respectively, up 29.2%, 57.1% and 25.6% respectively. Based on the COPD assessment, the number of patients in group A increased by 12.1% compared with that before recovery, while those in group B, C and D decreased by 7.2%, 3.5% and 1.6% respectively. Conclusion: Through the comprehensive intervention management of patients with stable COPD, clinical symptoms can be alleviated, the risk of the disease can be decreased, and the quality of life can be improved. Provide the basis for community management and intervention of COPD in Xinjiang.