The Effect of Elderly Care and Medical Services Integration Model on Quality of Life in Elderly People：a Meta-analysis

doi:10.12114/j.issn.1007-9572.2019.00.009

Abstract

Abstract: Background　According to the latest world population aging data released by the United Nations Population Division，the proportion of people aged over 60 years has risen from 8.5% in 1980 to 12.7% in 2017，which is expected to double by 2050. In China，the population aged 60 years and over accounts for 16.2% in 2017，which is estimated to reach 35.1% in 2050，posing a extremely grim aging trend. To achieve healthy aging，China has proposed a model of combination of elderly care and medical services. However，compared with the abundant and mature old-age care models in western developed countries，the benefit and content of the combination of medical and health care model should be further verified and improved. Objective　Domestic and foreign randomized controlled trials （RCT） on the effect of elderly care and medical services integration model were systemically retrieved to evaluate its effect on improving the quality of life among the elderly，so as to provide reliable reference for the exploration and development of elderly care and medical services integration model. Methods　The systematic evaluation method provided by Cochrane Collaboration Network was used systemically and comprehensively to retrieve databases，including Cochrane Library，Web of knowledge，Medline，EMBase，Chinese Biological Medical Literature Database （CBM），CNKI，Wanfang Data Knowledge Service Platform，and VIP．Meanwhile，references cited in literature were also screened，and relevant periodicals and gray literature were manually retrieved until 30th December，2017，so as to enroll RCT on providing elderly care and medical services integration model for the elderly. The methodological quality of enrolled literature was evaluated by two reviewers independently using Cochrane Interventions Systematic Review Manual，and the RevMan 5.3 software was used for meta-analyses. Results　A total of 15 studies involving 2 958 subjects were enrolled. According to the Cochrane evaluation tool，two of them were of grade B，and thirteen were of grade C. Results of meta-analysis suggested that PF score，RP score，BP score，GH score，VT score，SF score，RE score，MH score and ADL score in intervention group were higher than those in control group〔MD=7.07，95%CI （4.89，9.25），P<0.000 01；MD=11.73，95%CI （6.98，16.48），P<0.000 01；MD=6.69，95%CI （0.26，13.12），P=0.04；MD=6.38，95%CI （3.13，9.62），P=0.000 1；MD=6.51，95%CI （3.62，9.40），P<0.000 01；MD=6.59，95%CI （4.08，9.10），P<0.000 01；MD=6.64，95%CI （2.19，11.09），P=0.003；MD=5.21，95%CI （1.35，9.08），P=0.008；MD=1.95，95%CI （0.16，3.73），P=0.03〕. Besides，difference in the CES-D score and MMSE score between intervention group and control group were not statistically significant〔MD=-0.93，95%CI （-3.07，1.21），P=0.40；MD=0.18，95%CI （-0.55，0.92），P=0.63〕. Moreover，the meta-analysis results were relatively stable by changing the effect model of meta-analysis and removing high-weight literature. Conclusion　Existing clinical researches have proven that elderly care and medical services integration model is more effective than traditional care in terms of improving the quality of life in elderly people. However，due to late development of this model in China and low quality and small sample size of existing research，more high-quality studies are needed for further research and exploration.

Key words: Combination of medical treatment and maintenance, Aged, Randomized controlled trial, Quality of life, Meta-analysis

摘要： 背景　据联合国人口司最新公布的世界人口老龄化数据显示，60岁及以上人口从1980年的8.5%上升到2017年的12.7%，预计到2050年此数量将再增加1倍，而中国地区2017年60岁及以上人口占16.2%，预计2050年将达到35.1%，老龄化形式十分严峻。为实现健康老龄化，我国提出发展“医养结合”养老模式，但相比西方发达国家丰富成熟的养老模式，“医养结合”养老模式的优越性及内容建设尚需进一步验证和完善。目的　通过全面检索国内外关于“医养结合”照护模式对老年人生活质量影响的随机对照试验（RCT），进一步评价其改善老年人生活质量的效果，以期为“医养结合”照护模式的探索及发展提供可靠的依据。方法　使用Cochrane协作网提供的系统评价方法，系统全面检索Cochrane Library、Web of Knowledge、Medline、EMBase、中国生物医学文献数据库（CBM）、中国知网、万方数据知识服务平台、维普网（VIP）等数据库。同时筛查纳入文献的参考文献，结合手工检索相关期刊及灰色文献，检索时间截至2017-12-30，纳入为老年人提供“医养结合”照护模式的RCT。由两名评价者采用Cochrane干预措施系统评价手册共同评价纳入文献的方法学质量，采用RevMan 5.3软件进行Meta分析。结果　共纳入15篇文献，包括2 958例研究对象。根据Cochrane评估工具，2篇为B级，13篇为C级。Meta分析结果显示，试验组生理机能（PF）评分、生理职能（RP）评分、躯体疼痛（BP）评分、一般健康状况（GH）评分、精力（VT）评分、社会功能（SF）评分、情感职能（RE）评分、精神健康（MH）评分、日常生活活动能力量表（ADL）评分均高于对照组〔均数差（MD）=7.07，95%CI（4.89，9.25），P<0.000 01；MD=11.73，95%CI（6.98，16.48），P<0.000 01；MD=6.69，95%CI（0.26，13.12），P=0.04；MD=6.38，95%CI（3.13，9.62），P=0.000 1；MD=6.51，95%CI（3.62，9.40），P<0.000 01；MD=6.59，95%CI（4.08，9.10），P<0.000 01；MD=6.64，95%CI（2.19，11.09），P=0.003；MD=5.21，95%CI（1.35，9.08），P=0.008；MD=1.95，95%CI（0.16，3.73），P=0.03〕。试验组和对照组流调用抑郁自评量表（CES-D）评分、简易精神状态检查量表（MMSE）评分比较，差异均无统计学意义〔MD=-0.93，95%CI（-3.07，1.21），P=0.40；MD=0.18，95%CI（-0.55，0.92），P=0.63〕。通过改变Meta分析效应量模型，以及删除高权重文献后，Meta分析结果比较稳定，未发生变化。结论　现有临床研究证据证明，“医养结合”照护模式在改善老年人生存质量上较常规照护模式更有效，但鉴于“医养结合”照护模式在我国起步晚、发展慢，现有研究质量不高以及样本量较小等，还需要更多高质量的研究进一步的研究和探索。

关键词: 医养结合, 老年人, 随机对照试验, 生活质量, Meta分析

LUO Jing,LIU Yao,LUO Yuru, et al. The Effect of Elderly Care and Medical Services Integration Model on Quality of Life in Elderly People：a Meta-analysis　[J]. Chinese General Practice, 2019, 22(17): 2075-2083. DOI: 10.12114/j.issn.1007-9572.2019.00.009.
罗婧,刘瑶,罗玉茹等. 医养结合照护模式对老年人健康相关生存质量影响的Meta分析[J]. 中国全科医学, 2019, 22(17): 2075-2083. DOI: 10.12114/j.issn.1007-9572.2019.00.009.

References

［1］宋全成，崔瑞宁.人口高速老龄化的理论应对—从健康老龄化到积极老龄化［J］．山东社会科学，2013，27（4）：36-41．DOI：10.14112/j.cnki.37-1053/c.2013.04.034.
SONG Q C，CUI R N.The theoretical response to the rapid population aging：from healthy aging to active aging［J］．Shandong Social Science，2013，27（4）：36-41．DOI：10.14112/j.cnki.37-1053/c.2013.04.034.
［2］中华人民共和国中央人民政府国务院办公厅.国务院关于加快发展养老服务业的若干意见［EB/OL］．（2013-09-13）［2018-03-20］．http：//www.gov.cn/zwgk/2013-09/13/content_2487704.htm.
［3］中华人民共和国中央人民政府国务院办公厅.国务院办公厅转发卫生计生委等部门关于推进医疗卫生与养老服务相结合指导意见的通知［EB/OL］．（2015-11-20）［2018-03-20］．http：//www.gov.cn/zhengce/content/2015-11/20/content_10328.htm.
［4］田冶，吴玲，王小丹，等．应用TOPSIS法和RSR法综合评价不同地区老年人生存质量［J］．中国卫生统计，2011，28（3）：286-287．DOI：10.3969/j.issn.1002-3674.2011.03.022.
TIAN Y，WU L，WANG X D，et al．Comprehensive evaluation of the quality of life of the elderly in different regions by TOPSIS and RSR［J］．Chinese Journal of Health Statistics，2011，28（3）：286-287．DOI：10.3969/ j.issn.1002-3674.2011.03.022.
［5］廖芮，张开宁，王华平，等．我国健康老龄化背景下的医养结合：基本理念、服务模式与实践难题［J］．中国全科医学，2017，20（3）：270-277．DOI：10.3969/j.issn.1007-9572.2017.03.003.
LIAO R，ZHANG K N，WANG H P，et al．Combination between medical and elderly care institutions under the background of healthy aging in China：basic concepts，service modes and problems in practice［J］．Chinese General Practice，2017，20（3）：270-277．DOI：10.3969/j.issn.1007-9572.2017.03.003.
［6］邓诺.健康老龄化背景下江苏省部分地区“医养结合”养老模式研究［D］．南京：南京医科大学，2016.
DENG N.The research for new old-age caring mode combining nursing home and hospital in Jiangsu Province［D］．Nanjing：Nanjing Medical University，2016.
［7］四川大学华西医院中国Cochrane中心.Cochrane干预措施系统评价手册中文翻译版［EB/OL］．（2014-12-01）［2018-04-03］．http：//training.cochrane.org/sites/training.cochrane.org/files/public/uploads/resources/CochraneHandbookChineseDec2014.pdf.
［8］王丹，翟俊霞，牟振云，等．Meta分析中的异质性及其处理方法［J］．中国循证医学杂志，2009，9（10）：1115-1118．DOI：10.3969/j.issn.1672-2531.2009.10.013.
WANG D，ZHAI J X，MOU Z Y，et al．Discussing on the research of heterogeneity in meta-analysis［J］．Chinese Journal of Evidence-Based Medicine，2009，9（10）：1115-1118．DOI：10.3969/j.issn.1672-2531.2009. 10.013.
［9］陈建峰，秦卫，张燕，等．养老机构老年人生活质量、营养状况的团队健康干预研究［J］．中国卫生产业，2016，13（19）：76-79．DOI：10.16659/j.cnki.1672-5654.2016.19.076.
CHEN J F，QIN W，ZHANG Y，et al．Research on effect of team health intervention on quality of life and nu-trition state in old people in senior care organization［J］．China Health Industry，2016，13（19）：76-79．DOI：10.16659/j.cnki. 1672-5654.2016.19.076.
［10］何洁，王莜蓊.医养结合护理模式对多病共存老年患者自护能力及生存质量的影响［J］．医学理论与实践，2015，28（15）：2086-2088．DOI：10.19381/j.issn.1001-7585.2015.15.079.
HE J，WANG X W.The influence of the mode of combining medical care with nursing care on self-care ability and quality of life of elderly patients with multiple diseases［J］．The Journal of Medical Theory and Practice，2015，28（15）：2086-2088．DOI：10.19381/j.issn.1001-7585.2015.15.079.
［11］蒲艺文.养老机构对老年人实施团队健康干预的研究［D］．重庆：重庆医科大学，2014.
PU Y W.Evaluation on the effect of allied health intervention for the elderly in nursing home［D］．Chongqing：Chongqing Medical University，2014.
［12］张洪.“中西医结合养老护理模式”在老年院中的应用研究［D］．成都：成都中医药大学，2012.
［13］赵敏.老年慢性病患者医养融合模式下出院后照护干预效果［J］．国际护理学杂志，2017，36（6）：755-757．DOI：10.3760/cma.j.issn.1673-4351.2017.06.011.
ZHAO M.Effect of nursing intervention after discharge from a hospitalized model of elderly patients with chronic diseases［J］．International Journal of Nursing，2017，36（6）：755-757．DOI：10.3760/cma.j.issn.1673-4351.2017.06.011.
［14］MARKLE-REID M，WEIR R，BROWNE G，et al．Health promotion for frail older home care clients［J］．J Adv Nurs，2006，54（3）：381-395．DOI：10.1111/j.1365-2648.2006.03817.x.
［15］MARKLE-REID M，BROWNE G，GAFNI A，et al．The effects and costs of a multifactorial and interdisciplinary team approach to falls prevention for older home care clients ‘at risk’ for falling：a randomized controlled trial［J］．Can J Aging，2010，29（1）：139-161．DOI：10.1017/S0714980809990377.
［16］MARKLE-REID M.Frail elderly home care clients：the effects and expense of adding nursing health promotion and preventive care to personal support services［J］．Dissertation Abstracts International，2002，65（1）：159.
［17］SHYU Y I，LIANG J，TSENG M Y，et al．Comprehensive and subacute care interventions improve health-related quality of life for older patients after surgery for hip fracture：a randomised controlled trial［J］．Int J Nurs Stud，2013，50（8）：1013-1024．DOI：10.1016/j.ijnurstu.2012.11.020.
［18］CAMERON I D，FAIRHALL N，LANGRON C，et al．A multifactorial interdisciplinary intervention reduces frailty in older people：randomized trial［J］．BMC Med，2013，11（1）：65．DOI：10.1186/1741-7015-11-65.
［19］METZELTHIN S F，ROSSUM E V，WITTE L P D，et al．Effectiveness of interdisciplinary primary care approach to reduce disability in community dwelling frail older people：cluster randomised controlled trial［J］．BMJ，2013，347（10）：f5264．DOI：10.1136/bmj.f5264.
［20］BURNS R，NICHOLS L O，MARTINDALE-ADAMS J，et al．Interdisciplinary geriatric primary care evaluation and management：two-year outcomes［J］．J Am Geriatr Soc，2000，48（1）：8-13．DOI：10.1111/j.1532-5415.2000.tb03021.x.
［21］CLARKE C E，PATEL S，IVES N，et al．Clinical effectiveness and cost-effectiveness of physiotherapy and occupational therapy versus no therapy in mild to moderate Parkinson's disease：a large pragmatic randomised controlled trial（PD REHAB）［J］．Health Technol Assess，2016，20（63）：1-96．DOI：10.3310/hta20630.
［22］SACKLEY C，WADE D T，MANT D，et al．Cluster randomized pilot controlled trial of an occupational therapy intervention for residents with stroke in UK care homes［J］．Stroke，2006，37（9）：2336-2341．DOI：10.1161/01.STR.0000237124.20596.92.
［23］BIERLEIN C，HADJISTAVROPOULOS H，BOURGAULT-FAGNOU M，et al．A six-month profile of community case coordinated older adults［J］．Can J Nurs Res，2006，38（3）：32-50.
［24］刘鸣.系统评价、Meta-分析设计与实施方法［M］．北京：人民卫生出版社，2011.
［25］刘金华.基于老年生活质量的中国养老模式选择研究［D］．成都：西南财经大学，2009.
LIU J H.Research on the choice of the patterns for the aged from of the aspect of the old people's quality of life［D］．Chengdu：Southwestern University of Finance and Economics，2009.
［26］JOHRI M，BELAND F，BERGMAN H.International experiments in integrated care for the elderly：a synthesis of the evidence［J］．Int J Geriatric Psychiatry，2003，18（3）：222-235．DOI：10.1002/gps.819.
［27］姜向群，魏蒙.中国高龄老年人日常生活自理能力及其变化情况分析［J］．人口与发展，2015，21（2）：93-100．DOI：10.3969/j.issn.1674-1668.2015.02.012.
JIANG X Q，WEI M.Activity of daily living of the Chinese oldest-old and its change between 2002 and 2011［J］．Population and Development，2015，21（2）：93-100．DOI：10.3969/j.issn.1674-1668.2015.02.012.
［28］仲亚琴，王健，张国杰.老年人日常生活能力现状及影响因素分析［J］．现代预防医学，2014，41（5）：852-855，861.
ZHONG Y Q，WANG J，ZHANG G J.Analysis on ability of daily living and its influence factors among the elderly［J］．Modern Preventive Medicine，2014，41（5）：852-855，861.
［29］牛田华，孟庆跃，孟祥臻，等．农村老年人日常生活活动能力现状及影响因素分析［J］．现代预防医学，2010，37（7）：1290-1291.
NIU T H，MENG Q Y，MENG X Z，et al．Analysis of the status about the ability of daily living of the rural elders in Shandong Province and its influencing factors［J］．Modern Preventive Medicine，2010，37（7）：1290-1291.
［30］王丽丽，陈长香，李淑杏，等．城市社区不同年龄老年人日常生活能力现状［J］．现代预防医学，2014，41（9）：1608-1610.
WANG L L，CHEN C X，LI S X，et al．The status of daily life ability of the older with different ages in community［J］．Modern Preventive Medicine，2014，41（9）：1608-1610.
［31］何燕，覃日英，全旭红.不同医养结合机构老年人总体幸福感调查及其影响因素研究［J］．中国全科医学，2017，20（29）：3649-3654．DOI：10.3969/j.issn.1007-9572.2017.00.058.
HE Y，QIN R Y，QUAN X H.General well-being and associated factors in elderly people receiving integrated medical and nursing care from different types of institutions［J］．Chinese General Practice，2017，20（29）：3649-3654．DOI：10.3969/j.issn.1007-9572.2017.00.058.
［32］韩杨，李红玉.锦州市老年人医养结合机构养老意愿及其影响因素分析［J］．中国全科医学，2018，21（12）：1456-1460．DOI：10.3969/j.issn.1007-9572.2018.00.087.
HAN Y，LI H Y.Analysis of the willingness of elderly people in Jingzhou City to choose medical-nurse combined care institutions and of associated influencing factors［J］．Chinese General Practice，2018，21（12）：1456-1460．DOI：10.3969/j.issn.1007-9572.2018.00.087.
［33］韩雨欣，龙芋君.老年人生存质量评估量表的研究进展［J］．中国疗养医学，2017，26（1）：21-24．DOI：10.13517/j.cnki.ccm.2017.01.008.
HAN Y X，LONG Y J.Research progress on the quality of life assessment scale for the elderly［J］．Chinese Journal of Convalescent Medicine，2017，26（1）：21-24．DOI：10.13517/j.cnki.ccm.2017.01.008.
［34］MICHALOS A C.Encyclopedia of quality of life and well-being research［M］．Dordrecht：Springer，2014.
［35］TSENG H M，LU J R，GANDEK B.Cultural issues in using the SF-36 health survey in Asia：results from Taiwan［J］．Health Qual Life Outcomes，2003，1（1）：72．DOI：10.1186/1477-7525-1-72.
［36］李锐臻，韩世范，程金莲，等．国内护理学领域高影响因子期刊中临床RCT文献的质量评价［J］．循证护理，2015，1（3）：101-105．DOI：10.3969/j.issn.2095-8668.2015.03.002.

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