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

摘要： 背景　心血管疾病是全球死亡的主要原因。经皮冠状动脉介入治疗（PCI）是目前常用的治疗心血管疾病的方法，可以明显降低冠心病死亡率，然而我国PCI治疗后患者随访依从性低，支架内再狭窄与心血管不良事件发生率较高。对PCI术后患者进行针对性的健康管理是减少其发生冠状动脉再狭窄、保护心脏功能、提高生存率并改善生活质量的主要措施。目的　探讨上海市徐汇区“1+1+1”家庭医生签约团队服务模式下冠心病PCI术后患者健康管理效果。方法　选取127例于2016年1—12月首次行PCI术并在社区卫生服务中心进行术后随访患者，随机分为干预组64例和对照组63例。对照组进行常规随访，干预组患者进行“1+1+1”签约，并提供以下签约服务：家庭医生随访进行冠心病防治健康教育、冠心病危险因素干预，专病门诊治疗及开具延伸处方，双向转诊及云平台联合诊疗。随访2年后，依据“国人缺血性心血管病发病危险的评估方法和简易评估工具”，比较两组患者血压、血糖、血脂等危险因素的控制情况及主要不良心血管事件（MACE）的发生情况。结果　两组患者临床基础资料无明显差异。随访2年后干预组血压、血糖、血脂的控制率均高于对照组（P<0.05）；干预组男性患者缺血性心血管病10年发病危险度低于对照组（P<0.05）；干预组患者PCI术后2年内心绞痛发生率低于对照组（P<0.05），复发性心肌梗死、心功能不全发生率及MACE合计发生率比较，差异无统计学意义（P>0.05）。结论　“1+1+1”家庭医生签约团队服务模式下对PCI术后患者进行健康管理，可以更好地控制患者冠心病危险因素，降低心绞痛发生率，降低男性患者缺血性心血管病10年发病危险度。

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