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冠状动脉粥样硬化性心脏病(冠心病)患者出院后从医院到家庭的过渡期管理面临巨大挑战,如缺乏自我管理知识、治疗依从性较差、发生出院后负性事件、医院社区间信息沟通和传递不足等,这些均可导致冠心病患者出院后近期时间内再入院的风险增加,危及患者安全,同时增加不必要的医疗费用。该文对国内外冠心病患者过渡期管理的定义、测评指标、影响因素及过渡期管理的干预措施和效果评价进行了综述,以期为我国开展安全、有效的冠心病患者过渡期管理提供参考和借鉴。
The transitional management of patients with coronary atherosclerotic heart disease (CHD) from hospital to home after leaving the hospital presents significant challenges such as lack of self-management knowledge, poor adherence to treatment, negative events after discharge, inter-hospital community information Inadequate communication and delivery, all of which can lead to an increased risk of re-admission in the near-term after discharge from patients with coronary heart disease, endangering patient safety and increasing unnecessary medical costs. This review summarizes the definition, evaluation index, influencing factors and interim measures and effect evaluation of transitional management of coronary heart disease patients both at home and abroad in order to provide reference for our country to carry out transitional management of safe and effective coronary heart disease patients. Learn from