Effectiveness of a family physician-integrated "Pulmonary Health Home" grid management model for community-based chronic obstructive pulmonary disease prevention and management
10.3760/cma.j.cn114798-20250316-00232
- VernacularTitle:家庭医生联合“肺康之家”网格化管理模式在慢性阻塞性肺疾病社区防治中应用的效果评价
- Author:
Feng JIN
1
;
Wangling LI
;
Zilun CAI
;
Fei XIE
;
Guojin LI
;
Ruiyan MO
;
Yinhuan LI
Author Information
1. 广东省东莞市麻涌镇社区卫生服务中心全科医学科，东莞 523133
- Publication Type:Journal Article
- Keywords:
Physicians, family;
Community networks;
Community health services;
Pulmonary disease, chronic obstructive;
Disease management
- From:
Chinese Journal of General Practitioners
2025;24(9):1083-1089
- CountryChina
- Language:Chinese
-
Abstract:
Objective:To evaluate the effectiveness of a family physician-integrated "Pulmonary Health Home" (PHH) grid management model for community-based prevention and management of chronic obstructive pulmonary disease (COPD).Methods:A randomized controlled trial (RCT) was conducted in Machong Town of Dongguan City from October 1st 2021 to September 30th 2024. The PHH platform was established, screening high-risk populations using the COPD Screening Questionnaire (COPD-SQ). Individuals scoring ≥16 underwent confirmatory pulmonary function tests (post-bronchodilator FEV?/FVC<0.7). A total of 120 clinically stable COPD patients were randomized to either the intervention group (PHH platform management) or control group (routine care). Outcomes including smoking behavior, COPD Assessment Test (CAT) scores, modified Medical Research Council (mMRC) dyspnea scale scores, frequency of acute exacerbations, and other indicators were assessed before the preintervention and after one year of management.Results:Among 4 572 screened individuals, 345 COPD cases were confirmed (detection rate: 7.55%), representing a 259% increase from the pre-intervention baseline (96 cases). After one year, compared to controls, the intervention group showed: significantly lower annual cigarette consumption (165.8±61.3 vs. 321.3±70.2, t=12.856),greater reduction in CAT scores (16.06±5.92 vs. 19.25±5.24, t=3.182), fewer acute exacerbations (0.71±0.32 vs. 2.46±0.48 times/year, t=24.503), higher patient satisfaction (87.9%(51/58) vs. 62.5%(35/56), χ2=10.203), better mastery of inhalation technique (82.4% (48/58) vs. 48.2%(27/56), χ2=13.843), increased clinician-patient interactions (13.5±3.2 vs. 4.2±1.5 times/year, t=19.876) (all P<0.05). Conclusion:The family physician-integrated PHH grid management model significantly enhances community-based COPD outcomes.
