基于系统动力学的慢性阻塞性肺疾病患者居家肺康复模型构建和运作机制研究

The effectiveness of pulmonary rehabilitation (PR) has been widely confirmed, but only 1% to 2% of COPD patients are involved in the medical institutions based PR program. Home-based PR programs do not need to go to the rehabilitation center, and do not rely on expensive rehabilitation equipment, the patients with the integration of PR training and daily activities. Preliminary studies found that home based PR can improve the exercise tolerance, relieve dyspnea symptoms and improve the quality of life among patients with COPD. According to this, this study developed research questions under the background of “Home caring of the aged” and “Home based care and nursing”, using the health belief model (HBM) and system dynamics (SD) modeling technology, specify the main body, boundary and causality of home based PR, then develop the “Home based PR model for patients with COPD” in China and to explore its operating mechanism. Using the “Home based PR model for patients with COPD” as the experimental platform, the internal structure and function defects of home based PR as a policy target, in order to provide theoretical and evidence support for the development of relevant health policies. In order to explore the potential rehabilitation medical resources, improve the basic medical and health service capacity of China.

肺康复的有效性获广泛临床证实，但只有1%～2%的慢性阻塞性肺疾病（COPD）患者参与基于医疗机构的肺康复，收益率极低。居家肺康复可解决上述问题，患者无需前往康复地点，不依赖于昂贵的康复设备，可把康复训练与日常活动相融合。前期研究发现，居家肺康复可提高患者运动耐力，减轻呼吸困难及提高生活质量。基于此，本研究围绕“居家养老”和“居家医疗及护理”提出科学问题，以“健康信念模式”理论为引导，采用“系统动力学”建模技术，明确居家肺康复的主体，边界及因果关系，构建COPD居家肺康复系统动力学模型，揭示我国开展居家肺康复的阻滞因素，获得潜在的开展COPD患者居家肺康复的途径和机制。采用构建的“居家肺康复系统动力学模型”为试验平台，以COPD患者居家肺康复内部结构与功能缺陷为政策靶点，以期为相关宏观卫生政策的研制提供理论和数据支持。以期挖掘潜在稀有而不显见康复医疗资源，提升我国基层医疗卫生服务能力。

我国多数老年人都不愿意离开自己熟悉的家庭环境，一般选择居家养老，这种居家养老的方式使得大部分的COPD患者长期生活在家庭环境中。在我国“居家养老”和“居家医疗护理”的大背景下，对COPD患者开展肺康复十分必要且迫在眉睫，COPD患者也具有强烈的需求接受肺康复训练。本研究全面系统收集在COPD患者中开展居家肺康复的相关数据，以期得到居家肺康复提供什么形式的康复，阻滞和影响因素是什么，为我国COPD患者居家肺康复模型的构建提供借鉴和参考。通过建立逻辑模型获得我国“居家养老”和“居家医疗”外部环境下，现有居家肺康复服务系统滞后、政策因素等导致系统输出效率低下的原因，获得解COPD患者居家肺康复结构性失衡、政策导向偏移的作用路径。患者健康状态、对肺康复认知、心理状况限制居家肺康复的开展。COPD患者合并症多，居家肺康复动力不足；患者对居家肺康复认知不足、信心不够；患者对居家肺康复不信任且锻炼依从性低；医护人员肺康复知识、培训及重视度不足限制居家肺康复的开展（医护人员自身知识储备不足、实施居家肺康复力不从心；居家肺康复服务开展规范化培训不足；医院、科室对居家肺康复重视度不够)；医疗组织层面提供居家肺康复服务的有限性(医院和社区家庭联动不足，后续追踪监测体系不完善;提供居家肺康复服务的专业人员不足；缺乏系统的康复训练模式及简便实用的效果评价指标)。