关键词: 社区；脑梗死; 恢复期；多学科；管理

Abstract:

Objective To study the effect of multidisciplinary management in community on secondary prevention in patients with cerebral infarction during recovery period. 

Methods A total of 172 discharged patients with cerebral infarction were randomly divided into management group (n =90) and control group (n =82). The neurologists, physical therapist, psychiatrists and nurses all got involved in multidisciplinary management of patients with cerebral infarction in community. The multidisciplinary management was performed in management group, and discharge instructions were performed in control group. The follow-up period was 6 months. The primary observation indictor was ischemic stroke recurrence, the secondary indictors included statin use, antiplatelet therapy, hypertension and diabetes treatment, the control rate of LDL-C, blood pressure and blood glucose, the NIHSS score and moderate-to-severity disability, post-stroke depression occurrence and the awareness rate of health education knowledge. 

Results Ischemic stroke recurrence had no significant difference between the two groups (P =0.196). The secondary indictors of the management group were all better than that of the control group (P <0.05). 

Conclusions The key of this multidisciplinary management model was that patients with cerebral infarction who discharge and return to the community bring standardized secondary prevention, rehabilitation and care programs to the community general practitioners, and thereby this promotes the formation of an patient-centered and interactive management model between specialists and general practitioners. Although this management model did not obviously reduce ischemic stroke recurrence, it could improve secondary prevention compliance and the control rate of risk factors, and improve the effect of secondary prevention.

Key words: Community; Cerebral infarction, convalescence; Multiple disciplines; Management