关键词: 家庭医生签约服务, 冠心病, 血管成形术, 气囊, 冠状动脉, 健康管理, 影响因素分析

Abstract: Background　Cardiovascular disease is the leading cause of death worldwide. Percutaneous coronary intervention（PCI），a commonly treatment for cardiovascular disease，can significantly reduce the mortality of coronary heart disease（CHD），but the post-PCI follow-up compliance is low and the incidence of post-PCI in-stent restenosis and cardiovascular adverse events is high in Chinese patients. Targeted health management for patients undergoing PCI is a key strategy to low the incidence of restenosis，protect heart function，and improve survival and quality of life. Objective　To evaluate the effect of "1+1+1" type of contracted services delivered by a family doctor team in Xuhui District of Shanghai in the management of post-PCI CHD patients. Methods　127 CHD patients treated with initial PCI between January and December 2016 who underwent post-PCI follow-up in our hospital were selected，and divided into control group（n=63） and intervention group （n=64） randomly，intervened with routine follow-up services，and "1+1+1" type of contracted family doctor services（health education on the prevention and treatment of CHD，and life style interventions for reducing CHD-related risk factors，continued outpatient pharmacological treatment prescribed by a specialist in the higher level hospital by family doctor team members，bi-directional referral services and online collaborative care via a could platform），respectively. The effects of intervention in two groups were evaluated after a 2-year follow-up by the control status of blood pressure，blood glucose and blood lipid and the incidence of major adverse cardiovascular events（MACE） using the "assessment methods and simple assessment tools of ischemic cardiovascular disease risk in Chinese adults". Results　There were no significant differences in baseline clinical factors between the groups. The follow-up showed that higher rate of blood pressure control，glycemic control or blood lipid control was found in the intervention group（P<0.05）. The men in the intervention group had lower 10-year risk for ischemic cardiovascular disease than those in the control group（P<0.05）. In terms of the incidence of MACE，the intervention group had a lower incidence of angina（P<0.05），but had similar incidence of recurrent myocardial infarction，cardiac insufficiency and overall incidence of MACE to the control group（P>0.05）. Conclusion　The "1+1+1" type of contracted services delivered by a family doctor team may better control cardiovascular risk factors，lower the incidence of angina in post-PCI CHD patients. Moreover，the services may also reduce the 10-year risk for ischemic cardiovascular disease in male patients.

Key words: Contracted family doctor services；Coronary disease；Angioplasty, balloon, coronary；Health management；Root cause analysis