关键词: 冠心病, 家庭医生团队, 社区卫生服务, 闭环管理路径, 全专联合, 自我管理, 不良心血管事件

Abstract: Background　In the context of hierarchical diagnosis and treatment，the prevention and treatment of coronary heart disease（CHD） as a typical chronic non-communicable disease，requires advanced intervention from specialist departments，and the continuous and standardized management at the community level indispensably.This study preliminarily explored the impact of a new closed-loop management mode collaborated by specialists and family doctors.Objective　To construct the closed-loop management team for patients with CHD and to evaluate its intervention effect.Methods　From January 2017 to January 2019，a total of 236 patients with CHD were randomly selected through simple random sampling method according to the electronic health records which were signed in the Pengpu New Estate Community Health Service Center of Shanghai.The patients were divided into the control group（n=122） and the study group（n=114） by random number table method.Patients in the control group received routine diagnosis，treatment and managemengt，patients in the study group were managed through the closed-loop management by family physicians team.All the patients were followed up for two years.The scores of Health-promoting Lifestyle ProfileⅡ（HPLPⅡ），CHD Knowledge and Cognition Questionnaire，Self-efficacy for Managing Chronic Disease 6-item Scale（SECD6） before and after 2-year interventionand，and the incidence of major adverse cardiac events（MACEs） during the following up were compared.Results　There were no significant differences in the scores of HPLPⅡ，CHD knowledge and cognition questionnaire，and SECD6 between the two groups before intervention（P>0.05）.After the 2-year intervention，the scores of HPLPⅡ，CHD knowledge and cognition questionnaire，and SECD6 were higher in study group than in control group（P<0.05）.Within 2-year follow-up，the incidence of MACEs in the study group was lower than that in the control group〔（1.8%，2/114） vs （8.2%，10/122），P<0.05〕，and the risk of MACEs in control group was about five times higher than that in study group〔95%CI（1.071，23.337）〕.Conclusion　The closed-loop management mode by family physicians team could effectively improve the self-management ability，self-efficacy and knowledge level of patients with CHD and it could improve the prognosis of patients.

Key words: Coronary disease, Family physicians team, Community health services, Closed-loop management, Combination of general practice and specialty, Self management, Major adverse cardiac events