基于干预映射的老年慢性心衰患者再入院风险评估模型构建与多学科全程康复管理策略研究

The readmission rate of patients with heart failure can reach 21.7% within 30 days after discharge. It has been found that 25% of patients’ unplanned readmission of 30 days after discharge can be avoided by early risk identification and timely intervention. There are fewer researches on multivariate risk assessment model for readmission of heart failure in China, and lack of prediction for readmission risk of heart failure patients. Therefore, this study will construct a risk assessment model for readmission and a multidisciplinary rehabilitation management strategy to reduce the readmission rate of elderly patients with chronic heart failure. Guided by the theory of intervention mapping, a multidisciplinary team will be set up first to construct a "risk assessment system for readmission of elderly patients with chronic heart failure" based on Andersen’s behavioral model, and to explore the risk factors affecting readmission of elderly patients with chronic heart failure from hospital to community. And further construct a readmission risk assessment model for elderly patients with chronic heart failure by Cox proportional risk regression model. Finally, based on "JBI Evidence-based Health Care Model", a scientific, whole-course and multidisciplinary rehabilitation management strategy from hospital to community was constructed. The management strategy was validated and optimized through a randomized controlled trial and focus group interviews. The results can provide theoretical reference to reduce the unplanned readmission rate of elderly patients with chronic heart failure, and promote the development of normative prevention and control and evidence-based decision-making of chronic heart failure in China.

心衰患者出院后30天再入院率可达21.7%，研究发现25%的患者出院后30天非计划再入院可通过早期风险识别和及时干预避免。国内关于建立多变量心衰患者再入院风险评估模型研究较少，缺乏对心衰患者再入院风险的预测。因此本研究拟构建再入院风险评估模型和多学科全程康复管理策略以降低老年慢性心衰患者再入院率。项目组以干预映射为理论指导，首先组建多学科团队，构建基于安德森行为模型的“老年慢性心衰患者再入院风险评估体系”，探索从医院到社区影响老年慢性心衰患者再入院的危险因素；进一步采用Cox比例风险回归模型构建老年慢性心衰患者再入院风险评估模型，及时准确预测再入院风险；最后基于“JBI循证卫生保健模式”，构建从医院到社区的科学、全程、多学科式康复管理策略，并通过随机对照试验和焦点小组访谈验证和优化管理策略。研究结果可为降低老年慢性心衰患者非计划再入院率提供理论参考，促进我国慢性心衰规范防控和循证决策开展。

心力衰竭（简称心衰）的高发病率、高死亡率、高再入院率和高医疗成本成为全世界各国共同面对的难题。降低心衰患者的再入院率，改善其预后是心衰管理中的最大挑战之一。精准评估老年慢性心衰患者的再入院风险可通过早期风险识别和及时干预降低再入院率。但目前国内有关心衰患者多变量再入院风险评估模型建立的研究较少。本研究通过文献回顾法、半结构式访谈及预调研，构建基于安德森行为模型的“老年慢性心衰患者再入院风险评估体系”，探索从医院到家庭影响老年慢性心衰患者再入院的危险因素；进一步采用多元Logistic回归模型构建老年慢性心衰患者出院30天后再住院预测列线图，及时准确预测再入院风险；最后基于自我决定理论，通过文献回顾法、专家咨询法及预试验，构建从医院到家庭的多学科团队式自主支持性管理方案，并通过随机对照试验对方案进行验证和应用研究。研究结果表明，4个维度、38个指标的“老年慢性心衰患者再住院风险评估工具”具有良好适用性和可行性，为调查老年慢性心衰患者的再住院危险因素提供了研究工具；老年慢性心衰患者出院30天后再住院预测列线图包括6个因素：手术史、自行改变药物类型、信息获取能力、主观支持、抑郁水平、生活质量，这些因素均与老年心衰患者30天再入院显著相关。列线图具有较好的鉴别能力且具有优越的临床适用性，可帮助专业人员识别心衰患者的个性化情况，以减少30天的再入院；基于自我决定理论的多学科团队式自主支持性管理方案可提升老年心衰患者自我护理能力水平、减轻焦虑、抑郁，并提高生活质量，干预后1个月效果仍显著，表明该方案在具有相似社会人口特征的心衰人群中具有实施潜力。该研究以干预映射为理论指导，构建的再住院风险评估工具、再住院预测列线图、多学科团队式管理方案填补了老年慢性心衰患者的再入院风险评估研究的空白，可为降低老年慢性心衰患者非计划再入院率提供理论参考，促进我国慢性心衰规范防控和循证决策开展。

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