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中华乳腺病杂志(电子版) ›› 2021, Vol. 15 ›› Issue (05) : 288 -294. doi: 10.3877/cma.j.issn.1674-0807.2021.05.004

论著

引导式护理模式在乳腺癌患者术后全方位管理中的应用
毛双玮1, 徐海萍1,†(), 张海云2, 金翠凤1, 文叶2, 李春艳2   
  1. 1. 210029　南京医科大学第一附属医院乳腺病科
    2. 210012　南京市雨花医院普外科
  • 收稿日期:2021-04-25 出版日期:2021-10-01
  • 通信作者: 徐海萍
  • 基金资助:
    2018年度江苏省妇幼健康科研重点资助项目(F201821); 江苏省人民医院临床能力提升工程(YHK202025)

Guided care for postoperative comprehensive management of breast cancer patients

Shuangwei Mao1, Haiping Xu1,†(), Haiyun Zhang2, Cuifeng Jin1, Ye Wen2, Chunyan Li2   

  1. 1. Department of Breast Diseases, First Affiliated Hospital of Nanjing Medical University, Nanjing 210036, China
    2. Department of General Surgery, Nanjing Yuhua Hospital, Nanjing 210012, China
  • Received:2021-04-25 Published:2021-10-01
  • Corresponding author: Haiping Xu
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引用本文：

毛双玮, 徐海萍, 张海云, 金翠凤, 文叶, 李春艳. 引导式护理模式在乳腺癌患者术后全方位管理中的应用[J/OL]. 中华乳腺病杂志(电子版), 2021, 15(05): 288-294.

Shuangwei Mao, Haiping Xu, Haiyun Zhang, Cuifeng Jin, Ye Wen, Chunyan Li. Guided care for postoperative comprehensive management of breast cancer patients[J/OL]. Chinese Journal of Breast Disease(Electronic Edition), 2021, 15(05): 288-294.

目的

探讨引导式护理模式对乳腺癌患者术后全方位管理的应用价值。

方法

根据纳入及排除标准，选取2019年1月至2020年3月在南京医科大学第一附属医院乳腺病科接受手术的来自南京市2个大型社区的女性乳腺癌患者160例作为研究对象进行前瞻性研究。试点社区患者为试验组、非试点社区患者为对照组，每组各80例。对照组采取全程个案管理模式，试验组采取引导式护理模式。分别在干预前1天、干预后3个月及6个月采用乳腺癌治疗功能评价量表(FACT-B)、创伤后成长量表(PTGI)及社会支持量表(SSRS)评价全部患者的生活质量、服药依从性、创伤后成长、社会支持情况；在干预后1、3、6个月，采用Morisky服药依从性量表评价2组中服用内分泌药物患者的用药依从性。各量表评分比较采用重复测量方差分析。

结果

在干预前1天、干预后3个月及6个月，试验组患者生活质量总分分别为87.61±8.23、98.59±8.13及103.01±8.30，对照组分别为87.50±9.02、91.50±8.59及96.35±7.62，试验组患者生活质量总分高于对照组(时间效应，F＝88.637, P<0.001；组间效应，F＝35.159, P<0.001；交互效应，F＝9.051，P<0.001)。在干预1、3、6个月，试验组患者的服药依从性得分分别为6.97±0.76、7.22±0.65及7.29±0.61，对照组分别为6.70±1.01、6.91±0.83及7.01±0.72，组间比较和不同时间点评分比较，差异均有统计学意义，但不存在交互效应(时间效应，F＝42.302, P<0.001；组间效应，F＝4.303, P＝0.040；交互效应，F＝0.718, P＝0.490)。在干预前1天、干预后3个月及6个月，试验组患者创伤后成长总分分别为63.58±8.95、72.95±10.30及75.95±8.58，对照组分别为63.25±7.98、68.61±8.92及74.69±9.32，组间比较和不同时间点评分比较，差异均有统计学意义，但不存在交互效应(时间效应，F＝75.279，P<0.001；组间效应，F＝5.123，P＝0.025;交互效应，F＝2.296, P＝0.102)。在干预前1天、干预后3个月及6个月，试验组患者社会支持总分分别为33.44±4.59、38.56±5.22及44.50±6.93，对照组分别为34.00±5.47、35.74±5.69及39.69±6.28，试验组患者社会支持总分高于对照组(时间效应，F＝74.906，P<0.001；组间效应，F＝21.712, P<0.001；交互效应，F＝8.800，P<0.001)。

结论

引导式护理模式可以提高乳腺癌患者术后生活质量、服药依从性、创伤后成长、社会支持，值得在临床推广应用。

关键词: 乳腺肿瘤, 乳房切除术, 个案管理师, 引导式护理
Objective

To explore the application of guided care in comprehensive management of breast cancer patients after surgery.

Methods

According to the inclusion and exclusion criteria, 160 female breast cancer patients who lived in two large communities of Nanjing and underwent surgery in the Department of Breast Diseases, First Affiliated Hospital of Nanjing Medical University from January 2019 to March 2020 were enrolled for a prospective study. The patients living in pilot area served as experimental group(n=80), and the patients living in non-pilot area served as control group(n=80). The patients in control group received whole-course case management and the patients in experimental group received guided care. The Functional Assessment of Cancer Therapy-Breast Cancer (FACT-B), Posttraumatic Growth Inventory (PTGI) and Social Support Rating Scale (SSRS) were used to evaluate the quality of life, post-traumatic growth and social support of all patients at 1 day before intervention, 3 and 6 months after intervention, respectively. The Morisky Medication Adherence Scale 8-item version was used to evaluate the medication compliance of patients taking endocrine drugs in both groups at 1, 3 and 6 months after intervention. The scores of each scale were analyzed with repeated measures analysis of variance.

Results

At 1 day before intervention, 3 and 6 months after intervention, the total scores of FACT-B in experimental group were 87.61±8.23, 98.59±8.13, and 103.01±8.30, which were significantly higher than 87.50±9.02, 91.50±8.59 and 96.35±7.62 in control group, respectively (time effect, F=88.637, P<0.001; grouping effect, F=35.159, P<0.001; interactive effect, F=9.051, P<0.001). At 1, 3 and 6 months after intervention, the scores of medication compliance were 6.97±0.76, 7.22±0.65 and 7.29±0.61 in experimental group, and 6.70±1.01, 6.91±0.83 and 7.01±0.72 in control group, suggesting a significant difference between groups and between different time points, but with no interaction (time effect, F=42.302, P<0.001; grouping effect, F=4.303, P=0.040; interactive effect, F=0.718, P=0.490). At 1 day before intervention, 3 and 6 months after intervention, the total scores of PTGI were 63.58±8.95, 72.95±10.30 and 75.95±8.58 in experimental group, and 63.25±7.98, 68.61±8.92 and 74.69±9.32 in control group, respectively, suggesting a significant difference between groups and between different time points, but with no interaction (time effect, F=75.279, P<0.001; grouping effect, F=5.123, P=0.025; interactive effect, F=2.296, P=0.102). At 1 day before intervention, 3 and 6 months after intervention, the total scores of SSRS were 33.44±4.59, 38.56±5.22 and 44.50±6.93 in experimental group, which were significantly higher than 34.00±5.47, 35.74±5.69 and 39.69±6.28 in control group, respectively (time effect, F=74.906, P<0.001; grouping effect, F=21.712, P<0.001; interactive effect, F=8.800, P<0.001).

Conclusion

The guided care can improve the quality of life, medication compliance, post-traumatic growth and social support of breast cancer patients in postoperative management, worthy of clinical application.

Key words: Breast neoplasms, Mastectomy, Case managers, Guided care
表1 2组乳腺癌患者的基线资料比较
变量 对照组(n＝80) 试验组(n＝80) 检验值 P值
年龄(岁，±s) 48.3±10.4 47.8±10.2 t＝0.346 0.730
学历[例(%)]        
  小学及以下 9(11.2) 7(8.7) Z＝-0.489 0.625
  初中、高中 46(57.5) 46(57.5)
  本科及以上 25(31.3) 27(33.8)
婚姻状况[例(%)]        
  未婚 1(1.2) 2(2.5) χ2＝0.833 0.808a
  已婚 73(91.3) 74(92.5)
  离异或丧偶 6(7.5) 4(5.0)
家庭月收入[例(%)]        
  <5 000元 12(15.0) 11(13.7) Z＝-0.098 0.922
  5 000~10 000元 40(50.0) 41(51.3)
  >10 000元 28(35.0) 28(35.0)
宗教信仰[例(%)]        
  有 5(6.2) 4(5.0)   1.000a
  无 75(93.8) 76(95.0)  
临床分期[例(%)]        
  Ⅰ~Ⅱ 59(73.8) 56(70.0) χ2＝0.278 0.598
  Ⅲ 21(26.2) 24(30.0)
表2 2组乳腺癌患者的乳腺癌治疗功能评价量表评分比较
项目 例数 生理状况 社会家庭状况 情感状况 功能状况 附加状况 总分
对照组              
  干预前1天 80 19.99±3.20 17.83±3.82 11.74±3.88 18.66±4.36 19.29±3.27 87.50±9.02
  干预后3个月 80 20.76±3.18 18.93±3.77 12.11±3.27 19.36±4.43 20.34±3.56 91.50±8.59a
  干预后6个月 80 21.64±2.36 20.04±4.30 13.19±3.53 20.31±4.17 21.18±3.13 96.35±7.62ab
试验组              
  干预前1天 80 19.94±3.18 18.24±4.09 11.94±3.80 18.48±4.59 19.03±3.03 87.61±8.23
  干预后3个月 80 21.68±2.91 20.14±3.81 14.20±3.20 20.90±3.87 21.68±3.77 98.59±8.13a
  干预后6个月 80 22.89±2.45 21.21±3.70 14.41±3.34 22.13±3.83 22.38±3.88 103.01±8.30ab
时间效应              
  F值   25.874 19.661 12.532 15.539 24.966 88.637
  P值   <0.001 <0.001 <0.001 <0.001 <0.001 <0.001
组间效应              
  F值   7.032 5.631 14.284 7.915 5.471 35.159
  P值   0.009 0.019 <0.001 0.006 0.021 <0.001
交互效应              
  F值   2.099 0.591 2.796 2.573 2.709 9.051
  P值   0.126 0.555 0.063 0.078 0.068 <0.001
表3 2组乳腺癌患者的Morisky服药依从性量表评分比较
组别 例数 干预后1个月 干预后3个月 干预后6个月
对照组 61a 6.70±1.01 6.91±0.83 7.01±0.72
试验组 59a 6.97±0.76 7.22±0.65 7.29±0.61
表4 2组乳腺癌患者的创伤后成长量表评分比较
项目 例数 人际关系 新可能性 个人力量 精神变化 欣赏生活 总分
对照组              
  干预前1天 80 20.89±4.53 15.70±4.16 12.55±3.87 5.10±1.88 9.01±3.41 63.25±7.98
  干预后3个月 80 22.48±5.03 16.56±4.35 13.95±3.51 5.16±1.66 10.46±3.18 68.61±8.92
  干预后6个月 80 24.26±4.93 19.65±4.08 14.45±3.79 5.58±1.99 10.75±2.92 74.69±9.32
试验组              
  干预前1天 80 20.85±5.09 15.83±4.63 12.80±4.01 5.16±2.31 8.94±3.56 63.58±8.95
  干预后3个月 80 25.11±6.01 17.34±4.07 14.14±3.27 5.41±1.95 10.95±3.38 72.95±10.30
  干预后6个月 80 25.31±5.22 19.09±3.99 14.60±3.56 5.61±1.82 11.34±3.16 75.95±8.58
时间效应              
  F值   24.882 33.625 10.454 2.391 17.793 75.279
  P值   <0.001 <0.001 <0.001 0.093 <0.001 <0.001
组间效应              
  F值   6.763 0.071 0.373 0.415 1.285 5.123
  P值   0.010 0.790 0.542 0.521 0.259 0.025
交互效应              
  F值   2.713 1.113 0.007 0.146 0.461 2.296
  P值   0.068 0.330 0.993 0.865 0.631 0.102
表5 2组乳腺癌患者的社会支持量表评分比较
项目 例数 客观支持 主观支持 对支持的利用度 总分
对照组          
  干预前1天 80 9.05±2.96 19.36±3.77 5.59±1.97 34.00±5.47
  干预后3个月 80 9.69±3.02 19.31±3.96 6.74±2.01a 35.74±5.69
  干预后6个月 80 10.71±4.21a 20.69±4.02 8.29±2.17ab 39.69±6.28ab
试验组          
  干预前1天 80 8.88±2.84 18.84±3.92 5.73±2.04 33.44±4.59
  干预后3个月 80 10.44±3.54a 20.90±3.81a 7.23±2.43a 38.56±5.22a
  干预后6个月 80 12.78±4.78ab 21.90±4.68a 9.83±2.00ab 44.50±6.93ab
时间效应          
  F值   21.386 11.784 103.442 74.906
  P值   <0.001 <0.001 <0.001 <0.001
组间效应          
  F值   7.158 4.275 14.115 21.712
  P值   0.008 0.040 <0.001 <0.001
交互效应          
  F值   3.480 3.104 4.891 8.800
  P值   0.033 0.046 0.008 <0.001
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