心脏康复转介服务

doi:10.3969/j.issn.1006-9771.2022.03.015

摘要/Abstract

摘要： 目的简介不同心脏康复转介体系。方法采取文献分析法,从中国知网、万方、PubMed、Web of Science等数据库,以及国内外心脏康复专业网站中获取心脏康复转介体系相关内容,进行综述。结果国外心脏康复的转介主要有基于电子病历管理系统的转介体系、基于互联网平台的转介体系、基于慢病护理模式的转介体系和以医院和社区为主的转介方式。我国基于医联体系统,尝试构建心脏康复转介体系。结论转介作为患者参与心脏康复的第一步,至关重要。相较于发达国家,我国心脏康复转介体系有待进一步完善。

关键词: 心脏康复, 转介体系, 心血管疾病, 综述

Abstract: Objective To summarize the cardiac rehabilitation referral system.Methods The literatures about the construction of cardiac rehabilitation referral systems were retrieved from the databases of CNKI, Wanfang Date, PubMed and Web of Science, and cardiac rehabilitation websites.Results For some foreign countries, the referrals of cardiac rehabilitation mainly based on electronic medical record management system, internet platform, chronic care model, and hospitals and communities. For China, referral system is trying to build based on the medical conjoined system.Conclusion Referral, as the first step, plays an important role in participating in cardiac rehabilitation for patients. The cardiac rehabilitation referral system needs to be improved in China, referred the ways of developed countries.

Key words: cardiac rehabilitation, referral system, cardiovascular diseases, review

秦宁,沈志莹,石双姣,李旭红,钟竹青. 心脏康复转介服务[J]. 《中国康复理论与实践》, 2022, 28(3): 366-372.

QIN Ning,SHEN Zhiying,SHI Shuangjiao,LI Xuhong,ZHONG Zhuqing. Cardiac rehabilitation referral service (review)[J]. 《Chinese Journal of Rehabilitation Theory and Practice》, 2022, 28(3): 366-372.

图/表 1

参考文献 47

[1]	World Health Organization. Cardiovascular diseases(CVDs) [EB/OL].(2021-06-11)[2021-07-23]. https://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds).
[2]	中国心血管健康与疾病报告编写组. 中国心血管健康与疾病报告2020概要[J]. 中国循环杂志, 2021,36(6):521-545.
	The Writing Committee of the Report on Cardiovascular Health and Diseases in China. Report on Cardiovascular Health and Diseases Burden in China: an Updated Summary of 2020[J]. Chin Circ J, 2021,36(6):521-545.
[3]	REGMI M R, BHATTARAI M, PARAJULI P, et al. Heart failure with preserved ejection fraction and 30-day readmission[J]. Clin Med Res, 2020,18(4):126-132.
[4]	CHAVA R, KARKI N, KETLOGETSWE K, et al. Multidisciplinary rounds in prevention of 30-day readmissions and decreasing length of stay in heart failure patients: a community hospital based retrospective study[J]. Medicine (Baltimore), 2019,98(27):e16233.
[5]	BISWAS S, DINH D, LUCAS M, et al. Incidence and predictors of unplanned hospital readmission after percutaneous coronary intervention[J]. J Clin Med, 2020,9(10):E3242.
[6]	HESS C N, KALTENBACH L A, DOLL J A, et al. Race and sex differences in post-myocardial infarction angina frequency and risk of 1-year unplanned rehospitalization[J]. Circulation, 2017,135(6):532-543.
[7]	AMBROSETTI M, ABREU A, CORRÀ U, et al. Secondary prevention through comprehensive cardiovascular rehabilitation: from knowledge to implementation. 2020 update. A position paper from the Secondary Prevention and Rehabilitation Section of the European Association of Preventive Cardiology[J]. Eur J Prev Cardiol, 2020,2020: 2047487320913379.
[8]	TURK-ADAWI K, SUPERVIA M, LOPEZ-JIMENEZ F, et al. Cardiac rehabilitation availability and density around the globe[J]. EClin Med, 2019,13:31-45.
[9]	ZHANG Z, PACK Q, SQUIRES R W, et al. Availability and characteristics of cardiac rehabilitation programmes in China[J]. Heart Asia, 2016,8(2):9-12.
[10]	BEATTY A L, BRADLEY S M, MAYNARD C, et al. Referral to cardiac rehabilitation after percutaneous coronary intervention, coronary artery bypass surgery, and valve surgery: data from the Clinical Outcomes Assessment Program[J]. Circ Cardiovasc Qual Outcomes, 2017,10(6):e003364.
[11]	GRAVERSEN C B, JOHANSEN M B, EICHHORST R, et al. Influence of socioeconomic status on the referral process to cardiac rehabilitation following acute coronary syndrome: a cross-sectional study[J]. BMJ Open, 2020,10(4):e036088.
[12]	THOMAS R J, KING M, LUI K, et al. AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services[J]. J Am Coll Cardiol, 2007,50(14):1400-1433.
[13]	PIEPOLI M F, HOES A W, AGEWALL S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts) Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR)[J]. Eur Heart J, 2016,37(29):2315-2381.
[14]	中国康复医学会心血管病专业委员会. 中国心脏康复与二级预防指南2018精要[J]. 中华内科杂志, 2018,57(11):802-810.
	Professional Committee of Cardiovascular Diseases of Chinese Society of Rehabilitation Medicine. Cardiac Rehabilitation and Secondary Prevention Guidelines 2018 Essentials in China[J]. Chin J Inte Med, 2018,57(11):802-810.
[15]	RITCHEY M D, MARESH S, MCNEELY J, et al. Tracking cardiac rehabilitation participation and completion among medicare beneficiaries to inform the efforts of a national initiative[J]. Circ Cardiovasc Qual Outcomes, 2020,13(1):e005902.
[16]	BORG S, ÖBERG B, LEOSDOTTIR M, et al. Factors associated with non-attendance at exercise-based cardiac rehabilitation[J]. BMC Sports Sci Med Rehabil, 2019,11:13.
[17]	Australian Cardiovascular Health and Rehabilitation Association. Heart Foundation Cardiac Rehabilitation Services Online Map[EB/OL].[2019-11-20]. https://www.acra.net.au/cr-services/heart-foundation-cardiac-rehabilitation-services-online-map/.
[18]	THOMAS R J, BALADY G, BANKA G, et al. 2018 ACC/AHA clinical performance and quality measures for cardiac rehabilitation: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures[J]. Circ Cardiovasc Qual Outcomes, 2018,11(4):e000037.
[19]	袁丽霞, 丁荣晶. 中国心脏康复与二级预防指南解读[J]. 中国循环杂志, 2019,34(z1):86-90.
	YUAN L X, DING R J. Interpretation of China's Guidelines for Cardiac Rehabilitation and Secondary Prevention[J]. Chin Circ J, 2019,34(z1):86-90.
[20]	中华医学会, 中华医学会杂志社, 中华医学会全科医学分会, 等. 冠心病心脏康复基层指南(2020年)[J]. 中华全科医师杂志, 2021,20(2):150-165.
	Chinese Medical Association, Chinese Medical Association Journal, Chinese Medical Association General Practice Branch, et al. Primary Guidelines for Coronary Heart Disease and Cardiac Rehabilitation (2020)[J]. Chin J Gene Prac, 2021,20(2):150-165.
[21]	PACK Q R, PRIYA A, LAGU T, et al. Cardiac rehabilitation utilization during an acute cardiac hospitalization: a national sample[J]. J Cardiopulm Rehabil, 2019,39(1):19-26.
[22]	Million Hearts. Million Hearts 2022—preventing 1 million heart attacks and strokes by 2022[EB/OL]. [2019-10-25].https://millionhearts.hhs.gov/files/MH-2022-Fact-Sheet.
[23]	Million Hearts. Focus Area: Referrals[EB/OL]. [2019-10-25].https://millionhearts.hhs.gov/tools-protocols/action-guides/cardiac-change-package/referrals.html.
[24]	ADES P A, KETEYIAN S J, WRIGHT J S, et al. Increasing cardiac rehabilitation participation from 20% to 70%: a road map from the Million Hearts Cardiac Rehabilitation Collaborative[J]. Mayo Clin Proc, 2017,92(2):234-242.
[25]	GOV.UK. Cardiovascular disease in south-west England[EB/OL]. [2019-10-27]. https://www.gov.uk/government/publications/cardiovascular-disease-in-south-west-england.
[26]	GOV.UK. National service framework: coronary heart disease[EB/OL]. [2019-10-27].https://www.gov.uk/government/publications/quality-standards-for-coronary-heart-disease-care.
[27]	MCCARTAN F, BOWERS N, TURNER J, et al. Introduction of a novel service model to improve uptake and adherence with cardiac rehabilitation within Buckinghamshire Healthcare NHS Trust[J]. BMC Cardiovasc Disord, 2017,17(1):184.
[28]	British Heart Foundation. Cardiac Rehabilitation Online Register[EB/OL]. [ 2019- 11- 07]. http://www.cardiac-rehabilitation.net/cardiac-rehab.htm.
[29]	Australian Cardiovascular Health and Rehabilitation Association. Heart Online[EB/OL].[2019-11-20]. https://www.acra.net.au/heart-online/.
[30]	British Heart Foundation. British Heart Foundation (BHF) National Audit of Cardiac Rehabilitation[EB/OL]. [ 2019- 11- 07]. http://www.cardiacrehabilitation.org.uk/about-us.htm.
[31]	GRACE S L, BENNETT S, ARDERN C I, et al. Cardiac Rehabilitation Series: Canada[J]. Prog Cardiovasc Dis, 2014,56(5):530-535.
[32]	YUAN G, SHI J, JIA Q, et al. Cardiac Rehabilitation: a Bibliometric Review from 2001 to 2020[J]. Front Cardiovasc Med, 2021,8:672913.
[33]	GRACE S L, CHESSEX C, ARTHUR H, et al. Systematizing inpatient referral to cardiac rehabilitation 2010: Canadian Association of Cardiac Rehabilitation and Canadian Cardiovascular Society joint position paper endorsed by the Cardiac Care Network of Ontario[J]. Can J Cardiol, 2011,27(2):192-199.
[34]	TRAN M, PESAH E, TURK-ADAWI K, et al. Cardiac Rehabilitation Availability and Delivery in Canada: How Does It Compare with Other High-income Countries?[J]. Can J Cardiol. 2018,34(10 Suppl 2):S252-S262.
[35]	SANDESARA P B, DHINDSA D, KHAMBHATI J, et al. Reconfiguring cardiac rehabilitation to achieve panvascular prevention: New Care Models for a New World[J]. Can J Cardiol, 2018,342(10SI):S231-S239.
[36]	GHANBARI-FIROOZABADI M, VAFAII NASAB M, BOOSTANI F, et al. Establishment of cardiac rehabilitation program in Yazd-Iran: an experience of a developing country[J]. Int J Cardiol Heart Vasc, 2019,24:100406.
[37]	GRACE S L, TURK-ADAWI K I, CONTRACTOR A, et al. Cardiac rehabilitation delivery model for low-resource settings[J]. Heart, 2016,102(18):1449-1455.
[38]	LIMA A P, NASCIMENTO I O, OLIVEIRA A C A, et al. Home-based cardiac rehabilitation in Brazil's public health care: protocol for a randomized controlled trial[J]. JMIR Res Protoc, 2019,8(11):e13901.
[39]	PRABHAKARAN D, CHANDRASEKARAN A M, SINGH K, et al. Yoga-based cardiac rehabilitation after acute myocardial infarction: a randomized trial[J]. J Am Coll Cardiol, 2020,75(13):1551-1561.
[40]	胡大一. 从中国心脏康复实践看"颠覆"医疗[J]. 慢性病学杂志, 2015,16(2):119-121.
	HU D Y. Chron Pathematol J, 2015,16(2):119-121.
[41]	丁荣晶, 高立敏, 褚亮, 等. 三级医院指导下社区主导的家庭自助心脏康复模式的有效性和安全性[J]. 中华心血管病杂志, 2017,45(3):209-216.
	DING R J, GAO L M, CHU L, et al. Efficacy and safety of tertiary hospital guided and community-driven family self-help cardiac rehabilitation model[J]. Chin J Cardiol, 2017,45(3):209-216.
[42]	沈玉芹. 互联网+三级医院与社区卫生服务中心心脏康复转诊模式解析[J]. 中国全科医学, 2019,22(21):2548-2550.
	SHEN Y Q. Cardiac rehabilitation referral model based on internet plus tertiary hospitals and community health centers[J]. Chin Gener Prac, 2019,22(21):2548-2550.
[43]	ALI S, BEHZAD H, SAEID K, et al. Barriers for the referral to outpatient cardiac rehabilitation: a predictive model including actual and perceived risk factors and perceived control[J]. Ann Cardiac Anaesth, 2018,21(3):249-254.
[44]	ZHOU Y, LI J, DU S, et al. Cardiac rehabilitation knowledge in patients with coronary heart disease in Baoding city of China: a cross-sectional study[J]. Int J Nurs Sci, 2017,4(1):24-28.
[45]	肖静, 黄伶智, 李乐之. 冠心病患者心脏康复信息需求现状及影响因素[J]. 中南大学学报(医学版), 2017,42(8):973-978.
	XIAO J, HUANG L Z, LI L Z. Demands for cardiac rehabilitation information in patients with coronary atherosclerotic heart disease and influential factors[J]. J Cent South Univ (Med Sci), 2017,42(8):973-978.
[46]	史珈铭, 刘晓婷. 老年人社区康复服务需求及其影响因素[J]. 中国康复理论与实践, 2021,27(3):334-340.
	SHI J M, LIU X T. Demands and determinants of community rehabilitation services for older adults[J]. Chin J Rehabil Theory Pract, 2021,27(3):334-340.
[47]	MOGHEI M, TURK-ADAWI K, ISARANUWATCHAI W, et al. Cardiac rehabilitation costs[J]. Int J Cardiol, 2017,244:322-328.

转介体系	代表国家	转介平台	主要转介时机	主要负责人	主要地点	主要优势	主要不足
基于EMR	美国	EMR	住院早期、门诊就诊	医疗保健者、专职联络人员	门诊心脏康复中心	实现标准化、自动化转介,利于跟踪、随访患者康复情况	系统衔接障碍、数据安全隐患、转介后注册率低
基于互联网平台	英国、澳大利亚	在线心脏康复注册平台、互联网信息门户	心脏事件发生后3 d内	初级保健团队、综合医院医务人员	社区康复中心、家庭	提高心脏康复普及率、转介率和参与率	缺乏标准化转介流程
基于CCM	加拿大	医疗保健系统	CCM	家庭医生、医疗专家、心脏康复团队	心脏康复中心	医患面对面沟通、服务满意度高,转介后依从性较好	转介效率不足
以医院和社区为主	伊朗、印度、印尼	暂无	暂无	外科医生、心脏病专家、住院心脏康复小组	医院、社区、家庭	医疗资源不充足情况下最大限度满足患者的服务需求	心脏康复团队服务质量参差不齐