目的 评价以脑心健康管理师为主导的“互联网＋”延续管理对脑血管病介入术后患者复诊率及健康风险因素的改善效果,为延续管理实践提供依据。方法 采用历史对照设计,连续纳入2024年5－10月于上海市某三级甲等医院行脑血管介入术并接受常规延续管理的55例患者为对照组,2024年11月至2025年8月接受脑心健康管理师主导的“互联网＋”延续管理的55例患者为观察组。比较两组患者术后3个月的复诊率、脑血管相关危险因素管控不良发生率、吸烟及饮酒行为发生率及满意率。结果 与对照组相比,观察组患者的复诊率提高(87.3% vs. 58.2%,P<0.05)。干预后,观察组脑血管相关危险因素管控不良发生率、吸烟行为发生率均下降,满意率显著提高,差异均有统计学意义(均P<0.05)。结论 脑心健康管理师主导的“互联网＋”延续管理,可有效提升脑血管病介入术后患者复诊率并改善健康风险因素管控率,值得推广。

Objective To evaluate the effects of “Internet Plus” continuing management led by brain-heart health managers on the follow-up visit rate and the improvement of health risk factors in patients after neurovascular intervention,so as to provide evidence for continuing management practice.Methods A historical control design was adopted.Fifty-five patients who underwent neurovascular intervention at a Grade A tertiary hospital in Shanghai from May 2024 to October 2024 and received routine continuing management were consecutively included as the control group,and fifty-five patients who received “Internet Plus” continuing management led by brain-heart health managers from November 2024 to August 2025 were included as the observation group.The two groups were compared in terms of the follow-up visit rate,the incidence of poorly controlled cerebrovascular-related risk factors,the prevalence of smoking and alcohol drinking,and the satisfaction rate at three months after surgery.Results Compared with the control group,the follow-up visit rate of the observation group was significantly higher (87.3% vs. 58.2%,P<0.05).After the intervention, the incidence of poorly controlled cerebrovascular-related risk factors and the incidence of smoking in the observation group were significantly decreased,and the satisfaction rate was significantly increased,with statistically significant differences(all P<0.05).Conclusions “Internet Plus” continuing management led by brain-heart health managers can effectively improve the follow-up visit rate and the control rate of health risk factors in patients after neurovascular intervention, and is worthy of promotion.

R473.74;R473.2;R823

国家卫生健康委员会脑卒中防治工程委员会中国脑卒中高危人群干预适宜技术研究及推广项目(GN-2020R0004；GN-2022R0010)；海军军医大学深蓝护理科研PI团队项目(2022KYP04)