Abstract: Background　In the context of hierarchical diagnosis and treatment，the prevention and treatment of coronary heart disease（CHD） as a typical chronic non-communicable disease，requires advanced intervention from specialist departments，and the continuous and standardized management at the community level indispensably.This study preliminarily explored the impact of a new closed-loop management mode collaborated by specialists and family doctors.Objective　To construct the closed-loop management team for patients with CHD and to evaluate its intervention effect.Methods　From January 2017 to January 2019，a total of 236 patients with CHD were randomly selected through simple random sampling method according to the electronic health records which were signed in the Pengpu New Estate Community Health Service Center of Shanghai.The patients were divided into the control group（n=122） and the study group（n=114） by random number table method.Patients in the control group received routine diagnosis，treatment and managemengt，patients in the study group were managed through the closed-loop management by family physicians team.All the patients were followed up for two years.The scores of Health-promoting Lifestyle ProfileⅡ（HPLPⅡ），CHD Knowledge and Cognition Questionnaire，Self-efficacy for Managing Chronic Disease 6-item Scale（SECD6） before and after 2-year interventionand，and the incidence of major adverse cardiac events（MACEs） during the following up were compared.Results　There were no significant differences in the scores of HPLPⅡ，CHD knowledge and cognition questionnaire，and SECD6 between the two groups before intervention（P>0.05）.After the 2-year intervention，the scores of HPLPⅡ，CHD knowledge and cognition questionnaire，and SECD6 were higher in study group than in control group（P<0.05）.Within 2-year follow-up，the incidence of MACEs in the study group was lower than that in the control group〔（1.8%，2/114） vs （8.2%，10/122），P<0.05〕，and the risk of MACEs in control group was about five times higher than that in study group〔95%CI（1.071，23.337）〕.Conclusion　The closed-loop management mode by family physicians team could effectively improve the self-management ability，self-efficacy and knowledge level of patients with CHD and it could improve the prognosis of patients.

Key words: Coronary disease, Family physicians team, Community health services, Closed-loop management, Combination of general practice and specialty, Self management, Major adverse cardiac events

摘要： 背景　在分级诊疗背景下，作为典型慢性非传染性疾病，冠心病的防治除需要专科先进的介入干预外，社区层面的持续性规范化管理起着必不可少的重要作用。本研究就全专联合、闭环管理的团队协同模式进行初步探索与实践。目的　构建家庭医生冠心病综合管理团队，评价家庭医生团队闭环路径管理对冠心病患者的干预效果。方法　于2017年1月—2019年1月，采用单纯随机抽样法在上海市彭浦新村街道社区卫生服务中心签约电子健康档案内抽取冠心病患者236例，采用随机数字表法分为对照组（n=122）和研究组（n=114）。对照组接受常规诊疗和管理，研究组由家庭医生团队进行闭环路径管理。比较两组干预前和干预2年后的健康促进生活方式量表（HPLPⅡ）、冠心病知识和认知问卷、慢性病自我效能量表得分，以及2年内的主要不良心血管事件（MACEs）发生情况。结果　干预前两组HPLPⅡ、冠心病知识和认知问卷、慢性病自我效能量表得分比较，差异无统计学意义（P>0.05）；干预后研究组HPLPⅡ、冠心病知识和认知问卷、慢性病自我效能量表得分高于对照组（P<0.05）。随访2年内，研究组的MACEs发生率低于对照组〔1.8%（2/114）比8.2%（10/122），P<0.05〕，对照组患者发生MACEs的风险约为研究组的5倍〔95%CI（1.071，23.337）〕。结论　家庭医生团队通过闭环路径管理能够有效提高冠心病患者的自我管理能力、自我效能及知识水平，并改善患者预后。

关键词: 冠心病, 家庭医生团队, 社区卫生服务, 闭环管理路径, 全专联合, 自我管理, 不良心血管事件