摘要目的:探讨家庭医生联合“肺康之家”网格化管理在慢性阻塞性肺疾病（慢阻肺病）社区防治中的效果。方法:采用随机对照试验，于2021年10月1日至2024年9月30日在东莞市麻涌镇构建“肺康之家”平台，采用慢阻肺病人群筛查问卷（COPD-SQ）筛查慢阻肺病高危人群并进一步行肺功能检查确诊。将纳入的120例稳定期慢阻肺病患者随机分为管理组（平台管理）与对照组（常规管理），评估管理前与管理1年后慢阻肺病患者吸烟情况、慢阻肺病自我评估测试（CAT）评分、改良版英国医学研究委员会呼吸困难问卷（mMRC）评分、急性加重次数等指标。结果:共发放COPD-SQ问卷4 831份，完成筛查4 572人，确诊慢阻肺病345例（7.55%，345/4572），较平台建立前（基线）新增确诊249例。管理1年后，与对照组相比，管理组患者当年吸烟支数更少［（165.8±61.3）支比（321.3±70.2）支， t=12.856］，CAT评分更低［（16.06±5.92）分比（19.25±5.24）分， t=3.182］，急性加重次数更少［（0.71±0.32）次比（2.46±0.48）次， t=24.503］，患者满意度显著提升［87.9%（51/58）比62.5%（35/56）， χ2=10.203］，吸入技术掌握率［82.4%（48/58）比48.2%（27/56）， χ2=13.843］和医患互动频次［（13.5±3.2）次/年比（4.2±1.5）次/年， t=19.876］更高，差异均有统计学意义（均 P<0.05）。 结论:基于家庭医生联合“肺康之家”网格化管理模式可提升慢阻肺病社区管理效果。

abstractsObjective: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.