基于生态瞬时评估和干预的关节置换患者康复锻炼依从性时变特征分析及优化策略研究

Utilization of joint replacement as a main treatment regime for end-stage osteoarthritis is worldwide and continuing to increase. Regular rehabilitation exercise is crucial for restoring joint function, relieving pain and improving quality of life. However, studies showed rehabilitation adherence of those patients needed to be improved. .This study introduces EMA and EMI technology from social psychology to explore the time-varying characteristics of rehabilitation adherence, to clarify potential intervention targets and then propose optimization strategies. Firstly, experiences of patients with joint replacement are explored through interviews and observations, and their needs in rehabilitation and influencing factors will be analyzed. Secondly, longitudinal follow-up survey and structural equation model are adopted to develop influencing mechanism model of rehabilitation adherence. Thirdly, the core monitoring indicators for EMA will be extracted from the influencing mechanism and App which serves for EMA will be developed by software company. Fourthly, EMA via the App will be launched for two months in patients taking joint replacement, and patients will be prompted to complete surveys when they practice rehabilitation exercise every time. MLM and TVEM will be utilized to explore the time-varying characteristics of rehabilitation adherence and the relationship between core indicators and adherence changes and the key time windows and nodes for optimization of adherence will be defined. Finally, optimization strategy for rehabilitation adherence will be constructed by combining its time-varying characteristics, EMI and visual feedback technology and improved by an expert panel discussion. .This study provides new ideas and research methods for management of health behaviors such as rehabilitation adherence, and can provide useful reference for self-monitoring and health services of other chronic patients.

作为终末期骨病的主要治疗措施，关节置换手术量大且呈上升趋势，术后规律康复锻炼对恢复关节功能、提高生活质量至关重要，但研究显示患者康复锻炼依从性有待提高。本研究拟引入心理学领域EMA和EMI探讨关节置换患者康复锻炼依从性的时变特征、明确干预靶点，进而提出依从性优化策略。首先，通过访谈、观察探讨康复期患者的体验，分析其心理需求及影响因素；基于此，初步构建康复锻炼依从性影响因素作用模型，通过纵向跟踪调查、结构方程模型等修订模型；基于该模型确定EMA核心监测指标并开发匹配App；在术后患者中实施为期2月的EMA，采用MLM和TVEM探讨康复锻炼依从性的时变特征及各监测指标与依从性变化的关系，明确依从性优化的关键时间窗和节点；据此结合数据可视化技术和EMI构建依从性优化策略并进行专家论证。本研究为患者依从性等健康行为的管理提供了新的思路和研究方法，可为其他慢性病患者的自我监测和健康服务提供有益借鉴。

随着人口老龄化，骨性关节炎发病率呈逐年递增趋势，作为终末期骨病主要治疗方法的关节置换手术的量也逐年上升。为了恢复关节功能、取得最佳康复结局，术后患者规律康复锻炼至关重要，但调查发现患者锻炼依从性不高，康复结局堪忧。现有干预措施效果不佳多与康复锻炼依从性的影响因素复杂、干预措施缺乏针对性有关，找出康复锻炼依从性的核心影响因素和制定针对性干预措施成为提升患者康复锻炼依从性的瓶颈问题。本项目首先通过对关节置换术后患者的深入访谈，分析得出该群体术后康复过程中存在缓解和控制疼痛、指导康复锻炼、提升疾病认知和被关爱等需求；结合文献分析、量性调查明确关节置换患者康复锻炼依从性的主要影响因素为康复自我效能感、疼痛灾难化及其家庭人均月收入；根据生态瞬时评估原理跟踪评估关节置换患者术后疼痛、康复锻炼等，采用时变特征模型等分析，发现男性患者、有关节置换史、服用口服镇痛药者报告更高的疼痛评分，年龄越大疼痛评分越低；患者在下午14点时疼痛感低于晨6点和晚上22点，据此提出干预靶点。结合患者康复需求及影响因素设计康复锻炼辅助App框架并交由软件公司开发形成关节置换护理服务平台，发挥指导、答疑、提醒和情感支持等功效。并在此基础上，从参与人员、内容、重点环节等角度提出了康复锻炼依从性优化的干预策略。本研究从关节置换患者术后康复结局核心环节-依从性入手，在质性、量性研究基础上分析患者康复锻炼依从性的主要影响因素和关键干预靶点，有效提升干预策略制定的针对性和有效性。所形成的成果已经部分应用于临床，获得患者、护士的欢迎和好评，是全面提供优质护理服务和创新“互联网+”服务的有益尝试。本研究将心理学研究中的生态瞬时评估技术应用于慢病管理中，为其他慢性病患者的自我监测和健康服务的研究提供了新思路和新方法。