Disease management system and method for aortic dissection patient

Abstract

The invention relates to the technical field of disease management, and discloses a disease management system and method for aortic dissection patients. The patient terminal of the system can collect physiological data of a patient in real time and record related risk factors, the mobile terminal performs survival risk assessment on the patient according to the physiological data and the related risk factors to obtain a comprehensive score, and generates a personalized disease management strategy based on the comprehensive score, so that early warning and risk identification can be realized. And the medical care terminal checks and modifies the personalized disease management strategy to determine the final personalized disease management strategy, so that the professionality and scientificity of the scheme can be ensured. According to the system, the body state of the patient is evaluated, the patient can know the disease condition of the patient more clearly, and through online guidance of medical staff, the health risk can be reduced, and the life quality of the patient is improved. Through the system, a more comprehensive and personalized disease management scheme can be provided for the aortic dissection patient.

Description

Technical Field

[0001] The present application relates to the technical field of disease management, and in particular to a disease management system and method for patients with aortic dissection. Background Art

[0002] It is necessary to improve the management and treatment of critically ill patients, improve the quality and efficiency of medical services, and reduce the waste of medical resources. Aortic dissection, as a serious cardiovascular disease, is characterized by rapid onset and high mortality. It is one of the common emergency and critical diseases. The survival rate of patients with aortic dissection can be significantly improved through early standardized clinical treatment. However, even if patients are successfully discharged from the hospital, they still face many risks, such as complications such as new dissections, organ ischemia, aneurysm formation or rupture. Especially in the first 2 years after the acute phase, the risk of death of patients reaches its peak.

[0003] Studies have found that regardless of the initial treatment, more than 60% of patients with aortic dissection will develop aneurysms within the next 5 years. 29% of patients will die from dissecting aneurysms or other aneurysm ruptures after surgery, and 17% to 25% of patients will develop new aneurysms. Therefore, long-term or even lifelong disease management is needed for discharged patients with aortic dissection to ensure their quality of life.

[0004] Existing technologies mostly use WeChat, telephone, home follow-up and other forms of disease management. However, these forms of disease management cannot identify risks in advance and are not personalized enough to achieve comprehensive management and support. Summary of the invention

[0005] The present application provides a disease management system for patients with aortic dissection to solve the problems in the prior art that risks cannot be identified in advance, the degree of personalization is insufficient, and all-round management and support cannot be achieved.

[0006] Correspondingly, the present application also provides a disease management method for patients with aortic dissection, to ensure the implementation and application of the above-mentioned system.

[0007] In order to solve the above technical problems, the present application discloses a disease management system for patients with aortic dissection, the system comprising:

[0008] The patient side is used to collect the patient’s physiological data and record relevant risk factors;

[0009] Mobile terminal, used to assess the patient's survival risk based on physiological data and related risk factors, obtain a comprehensive score, and generate personalized disease management strategies based on the comprehensive score;

[0010] The medical and nursing side is used to review and modify the personalized disease management strategy and determine the final personalized disease management strategy.

[0011] Preferably, the physiological data includes basic information, physical sign data, movement data, psychological state change data, medication compliance and imaging data;

[0012] The patient side includes:

[0013] Basic information entry module, used to enter the patient's basic information;

[0014] Vital sign monitoring module, used to collect vital sign data of patients;

[0015] Lifestyle monitoring module, used to collect patients' vital signs and exercise data;

[0016] The psychological status assessment module is used to collect data on changes in the patient's psychological status;

[0017] Medication monitoring module, used to monitor patients' medication compliance;

[0018] The imaging examination result module is used to collect imaging data of patients during follow-up.

[0019] Preferably, the mental state assessment module monitors the patient's mental state change data based on galvanic skin response.

[0020] Preferably, the mobile terminal includes:

[0021] The risk assessment module is used to analyze physiological data and related risk factors through the Cox proportional hazards model to obtain a comprehensive score for the patient;

[0022] A risk stratification module is used to classify the comprehensive score according to the preset risk stratification criteria to determine the risk stratification level of the patient;

[0023] The strategy generation module is used to generate personalized disease management strategies based on the comprehensive score and risk stratification level.

[0024] Preferably, the personalized disease management strategy includes a care plan, lifestyle recommendations, and follow-up plan recommendations;

[0025] The medical side includes:

[0026] Nursing plan guidance module, which is used to review and modify the nursing plan, convert the tasks and time nodes in the final nursing plan into reminders, obtain the final nursing plan, and send the final nursing items and reminders to the patient through the mobile terminal;

[0027] Lifestyle guidance module, used to review and modify lifestyle suggestions, obtain final lifestyle suggestions, and send the final lifestyle suggestions to the patient via the mobile terminal;

[0028] The follow-up plan guidance module is used to review and modify the follow-up plan suggestions, obtain the final follow-up plan, and send the final follow-up plan to the patient through the mobile terminal.

[0029] Preferably, the patient end also includes a disease management module for viewing the final care plan, final lifestyle recommendations and final follow-up plan.

[0030] Preferably, the disease management module is also used for online viewing of popular science knowledge, online consultation, appointment for medical treatment and emergency calls.

[0031] Preferably, the patient end also includes:

[0032] The problem feedback module is used by patients to report their unpleasant experiences when using the disease management system;

[0033] The task points module is used to display pushed health tasks and record relevant points after the patient completes the corresponding health tasks, instructing the patient to use the points to obtain corresponding rewards.

[0034] Preferably, the medical end also includes:

[0035] The registration and login module is used to input the personal information of medical staff and assign corresponding system permissions;

[0036] The online answer module is used by medical staff to answer questions raised by patients online.

[0037] The present application also discloses a disease management method for patients with aortic dissection, which is implemented based on the disease management system for patients with aortic dissection in the present application, and the method comprises:

[0038] Collect the patient's physiological data and record relevant risk factors at the patient end;

[0039] On the mobile terminal, the patient's survival risk is assessed based on physiological data and related risk factors to obtain a comprehensive score, and a personalized disease management strategy is generated based on the comprehensive score;

[0040] The personalized disease management strategy is reviewed and modified on the medical and nursing side to determine the final personalized disease management strategy.

[0041] This application has at least the following beneficial effects:

[0042] (1) In this application, the patient side can collect the patient's physiological data and record relevant risk factors in real time. The mobile side can evaluate the patient's survival risk based on the physiological data and relevant risk factors, obtain a comprehensive score, and generate a personalized disease management strategy based on the comprehensive score, which can achieve early warning and risk identification. The medical side reviews and modifies the personalized disease management strategy and determines the final personalized disease management strategy to ensure the professionalism and scientific nature of the plan. The system in this application evaluates the patient's physical condition so that the patient can have a clearer understanding of his or her disease condition, and through the online guidance of medical staff, it can reduce health risks and improve the patient's quality of life. The system can provide a more comprehensive and personalized disease management plan for patients with aortic dissection.

[0043] (2) Integrate multidisciplinary expert resources, provide remote consultation and online consultation, and ensure that patients receive professional support.

[0044] (3) Establish real-time communication channels, provide education and emergency guidance, and enhance patients' self-management capabilities.

[0045] (4) Develop a one-click emergency call function to ensure that patients can quickly receive medical assistance in unexpected situations.

[0046] (5) Establish a user feedback mechanism to continuously optimize system functions through surveys and community interactions.

[0047] Additional aspects and advantages of the present application will be given in the following description, which will become apparent from the following description, or will be understood through the practice of the present application. BRIEF DESCRIPTION OF THE DRAWINGS

[0048] The above and / or additional aspects and advantages of the present application will become apparent and easily understood from the following description of the embodiments in conjunction with the accompanying drawings, in which:

[0049] Figure 1 A structural framework diagram of a disease management system for patients with aortic dissection provided in an embodiment of the present application;

[0050] Figure 2 A diagram showing the components of a disease management system for patients with aortic dissection provided in an embodiment of the present application;

[0051] Figure 3 A flow chart of a disease management method for patients with aortic dissection provided in an embodiment of the present application. DETAILED DESCRIPTION

[0052] The embodiments of the present application are described in detail below, and examples of the embodiments are shown in the accompanying drawings, wherein the same or similar reference numerals throughout represent the same or similar elements or elements having the same or similar functions. The embodiments described below with reference to the accompanying drawings are exemplary and are only used to explain the present application, and cannot be interpreted as limiting the present application.

[0053] It will be understood by those skilled in the art that, unless expressly stated, the singular forms "one", "said", and "the" used herein may also include plural forms. It should be further understood that the term "comprising" used in the specification of the present application refers to the presence of features, integers, steps, operations, elements and / or components, but does not exclude the presence or addition of one or more other features, integers, steps, operations, elements, components and / or combinations thereof. It should be understood that when we refer to an element as being "connected" or "coupled" to another element, it may be directly connected or coupled to the other element, or there may be an intermediate element. In addition, the "connection" or "coupling" used herein may include wireless connection or wireless coupling. The term "and / or" used herein includes all or any unit and all combinations of one or more associated listed items.

[0054] Those skilled in the art will appreciate that, unless otherwise defined, all terms (including technical and scientific terms) used herein have the same meaning as those generally understood by those skilled in the art in the field to which the present invention belongs. It should also be understood that terms such as those defined in general dictionaries should be understood to have meanings consistent with the meanings in the context of the prior art, and will not be interpreted with idealized or overly formal meanings unless specifically defined as here.

[0055] The solution provided in the embodiments of the present application can be executed by any electronic device, such as a terminal device or a server, wherein the server can be an independent physical server, a server cluster or a distributed system composed of multiple physical servers, or a cloud server that provides cloud computing services. The terminal can be a smart phone, a tablet computer, a laptop computer, a desktop computer, a smart speaker, a smart watch, etc., but is not limited to this. The terminal and the server can be directly or indirectly connected via wired or wireless communication, and this application does not limit this. With respect to the technical problems existing in the prior art, the disease management system and method for patients with aortic dissection provided in this application are intended to solve at least one of the technical problems of the prior art.

[0056] The technical solution of the present application and how the technical solution of the present application solves the above-mentioned technical problems are described in detail below with specific embodiments. The following specific embodiments can be combined with each other, and the same or similar concepts or processes may not be repeated in some embodiments. The embodiments of the present application will be described below in conjunction with the accompanying drawings.

[0057] The present application embodiment provides a disease management system for patients with aortic dissection, such as Figure 1 As shown, the system includes:

[0058] The patient end 101 is used to collect the patient's physiological data and record relevant risk factors;

[0059] The mobile terminal 102 is used to evaluate the survival risk of the patient based on the physiological data and relevant risk factors, obtain a comprehensive score, and generate a personalized disease management strategy based on the comprehensive score;

[0060] The medical care end 103 is used to review and modify the personalized disease management strategy and determine the final personalized disease management strategy.

[0061] The system in the embodiment of the present application has the advantage of multi-platform support and can be used on a variety of devices, such as mobile applications, web pages, applets, etc., which is convenient for patients to manage their movements anytime and anywhere. Among them, the patient end can provide a convenient mobile interface for patients, and the patient end will collect physiological data and transmit the recorded related risk factors to the mobile end. As the data center and decision support center of the system, the mobile end is responsible for data processing, storage, analysis and report generation, and sends the generated comprehensive evaluation report and personalized disease management strategy to the medical end. The medical end provides a work platform for medical staff to view the relevant patient data sent by the mobile end, formulate nursing plans, and communicate with patients. The medical end can review and modify the personalized disease management strategy generated by the mobile end, and send the modified personalized disease management strategy to the mobile end, which is distributed to the corresponding patient end by the mobile end, so that the patient can view and execute the corresponding personalized disease management strategy on the patient end.

[0062] In the embodiment of the present application, the patient end can collect the patient's physiological data and record relevant risk factors in real time. The mobile end evaluates the patient's survival risk based on the physiological data and relevant risk factors, obtains a comprehensive score, and generates a personalized disease management strategy based on the comprehensive score, which can achieve early warning and risk identification. The medical end reviews and modifies the personalized disease management strategy and determines the final personalized disease management strategy to ensure the professionalism and scientificity of the plan. The system in the embodiment of the present application evaluates the patient's physical condition so that the patient can have a clearer understanding of his or her own disease condition, and through the online guidance of medical staff, it can reduce health risks and improve the patient's quality of life. The system can provide a more comprehensive and personalized disease management plan for patients with aortic dissection.

[0063] In an optional embodiment, the physiological data includes basic information, physical sign data, movement data, psychological state change data, medication compliance, and imaging data during follow-up;

[0064] The patient side includes:

[0065] The basic information entry module is used to enter the patient's basic information; patients can log in through the mini program or APP, and enter the patient's basic information after logging in, including but not limited to name, age, gender, height, weight, BMI index, ID number, contact information and medical history.

[0066] The vital signs monitoring module is used to collect the patient's vital signs data; the patient's vital signs data, mainly including blood pressure and heart rate, can be monitored in real time through smart watches and mobile terminals. In the embodiment of the present application, the blood pressure monitoring frequency can be automatically adjusted according to the different blood pressure values ​​of the patient based on the collected vital signs data. When the systolic blood pressure is less than 90mmHg or greater than 140mmHg, an early warning prompt is given, which includes text reminders, sound reminders, and vibration reminders.

[0067] The lifestyle monitoring module is used to collect the patient's vital sign data and exercise data. The patient's vital sign data and exercise data can be collected in real time through a smart watch. The vital sign data include heart rate and blood pressure. Lifestyle characteristics are extracted through the vital sign data and exercise data to obtain the patient's lifestyle habits. It is mainly used to record the patient's daily activities, smoking, drinking and work and rest patterns.

[0068] The psychological state assessment module is used to collect data on changes in the patient's psychological state; data on changes in psychological state include but are not limited to a calm and relaxed state, a slightly tense, uneasy, excited, and agitated state, a moderately tense, anxious, excited, and agitated state, a highly tense, anxious, excited, and agitated state, and an extremely panic, fear, excitement, and agitated state.

[0069] The medication monitoring module is used to monitor the patient's medication compliance; optionally, the type and frequency of medication required for the aortic dissection patient's treatment plan are clearly defined, and the patient's medication compliance is derived based on the type and frequency of medication actually uploaded by the patient.

[0070] The imaging examination result module is used to collect imaging data of patients during follow-up; optionally, through the associated hospital WeChat official account, after real-name authentication, the aortic CTA / MRI, transthoracic echocardiogram, chest X-ray or electrocardiogram examination during the patient's follow-up can be recorded to monitor signs of dissection progression, new dissection or aneurysm formation.

[0071] In an optional embodiment, the mental state assessment module monitors the patient's mental state change data based on galvanic skin response.

[0072] In the embodiment of the present application, the change of the patient's skin conductivity can be sensed by a smart watch. Before the monitoring begins, the patient's skin conductance level in a calm state for 1-2 minutes is recorded as the baseline value, and the peak conductance obtained by the patient in a certain period of time, that is, the maximum value of the conductance response, is recorded. Among them, the psychological state can be calculated by the following formula:

[0073] △SCR=peak conductance-basic conductance level

[0074] No reaction: △SCR < 0.1μS, in a calm and relaxed state;

[0075] Mild reaction: 0.1μS≤△SCR<1.0μS, in a state of slight tension, anxiety, excitement, and agitation;

[0076] Moderate reaction: 1.0μS≤△SCR<5.0μS, in a state of moderate tension, anxiety, excitement, and agitation;

[0077] Strong reaction: 5.0μS≤△SCR<10.0μS, in a state of high tension, anxiety, excitement, and agitation;

[0078] Extreme reaction: △SCR ≥ 10.0μS, in a state of extreme panic, fear, excitement, and agitation;

[0079] In the formula, △SCR represents the amplitude of the conductance response, that is, the difference between the peak conductance and the basal conductance level. The changes in the patient's psychological state are judged based on the amplitude of the conductance response.

[0080] In an optional embodiment, the mobile terminal includes:

[0081] The risk assessment module is used to analyze physiological data and related risk factors through the Cox proportional hazards model to obtain a comprehensive score for the patient;

[0082] A risk stratification module is used to classify the comprehensive score according to the preset risk stratification criteria to determine the risk stratification level of the patient;

[0083] The personalized disease management generation module is used to generate personalized disease management strategies based on the comprehensive score and risk stratification level.

[0084] In the embodiment of the present application, the mobile terminal uses the Cox proportional hazard model to predict the time of the event of a change in the condition of patients with aortic dissection, and the survival risk analysis is calculated by the following formula:

[0085] h(t|X)=h0(t)exp(β1X1+β2X2+…+β n X n )

[0086] where h(t|X) is the hazard function at time t, h0(t) is the baseline hazard function, β1, β2, ...β n is the coefficient of the covariate, X 1， X 2， ...X n is a covariate. Covariates are relevant physiological data collected from the patient, such as age, gender, history of hypertension, type of surgery, medication compliance, lifestyle, changes in psychological state, and imaging examinations. Based on the above Cox proportional hazard model, the patient's comprehensive score h(t|X) can be calculated. By simultaneously analyzing the impact of multiple covariates on survival time, it helps to identify key risk factors and develop personalized management strategies.

[0087] In the embodiment of the present application, the mobile terminal can risk stratify the patient according to the score and determine the patient's risk stratification level.

[0088] Optionally, risk stratification mainly includes:

[0089] High risk: composite score above the 90th percentile;

[0090] Medium risk: the combined score is greater than the 50th percentile combined score and less than the 90th percentile;

[0091] Low risk: composite score below the 50th percentile;

[0092] The higher the risk level, the lower the patient survival rate. High-risk patients should increase the frequency of follow-up, adjust treatment plans, and optimize nursing measures; medium-risk patients should have regular follow-up, monitor key health indicators, and adjust management strategies in a timely manner; low-risk patients should maintain regular follow-up, pay attention to lifestyle improvements, and prevent recurrence.

[0093] In an optional embodiment, the personalized disease management strategy includes a care plan, lifestyle recommendations, and follow-up plan recommendations;

[0094] The medical side includes:

[0095] The nursing plan guidance module is used to review and modify the nursing plan, convert the tasks and time nodes in the final nursing plan into reminders, obtain the final nursing plan, and send the final nursing matters and reminders to the patient through the mobile terminal; the patient performs the corresponding nursing plan tasks according to the corresponding reminder information, the main contents of which are measuring blood pressure, heart rate monitoring, blood sugar determination and taking medicine as required.

[0096] The lifestyle guidance module is used to review and modify lifestyle recommendations, obtain final lifestyle recommendations, and send the final lifestyle recommendations to the patient via the mobile terminal; the main contents of the final lifestyle recommendations are diet plan adjustment, exercise selection, weight control, avoiding exposure to tobacco environments, and controlling drinking, etc.

[0097] The follow-up plan guidance module is used to review and modify follow-up plan recommendations, obtain the final follow-up plan, and send the final follow-up plan to the patient through the mobile terminal. For example, medical staff need to clarify individualized follow-up plans based on the patient's current abnormal conditions, whether family members have aortic dissection and a history of postoperative complications, the current aneurysm size and the degree of its change over time. It is recommended that patients with aortic dissection be followed up for at least 5 years after discharge, with follow-up at 1, 3, 6, 12 months after discharge and every year thereafter. If abnormalities occur, the follow-up frequency needs to be increased.

[0098] In an optional embodiment, the medical end further includes:

[0099] The registration and login module is used to enter the personal information of medical staff and assign corresponding system permissions; medical staff log in through the mini program or APP to enter the hospital where the medical staff works, work number, and practice certificate number. The medical registration and login module assigns corresponding system permissions to doctors according to their duties, positions, and professional expertise, allowing cross-institutional collaboration and resource sharing between different medical staff. The embodiment of this application integrates multidisciplinary expert resources, provides remote consultation and online consultation, and ensures that patients receive professional support.

[0100] The online answer module is used by medical staff to answer questions raised by patients online; when patients ask questions online, they will be reminded by text messages, phone calls, etc. to provide timely answers to medical staff.

[0101] In an optional embodiment, the patient side also includes a disease management module for viewing the final care plan, final lifestyle recommendations and final follow-up plan. The disease management module can receive reminder information and the corresponding final care plan sent by the medical side. The patient can perform the corresponding care plan tasks according to the reminder information, mainly measuring blood pressure, heart rate monitoring, blood sugar determination and medication as required. The disease management module can receive the final lifestyle recommendations sent by the medical side. The patient adjusts the corresponding lifestyle habits through the final lifestyle recommendations, mainly including diet adjustment, exercise selection, weight control, avoiding exposure to tobacco environments, and controlling drinking. The disease management module can receive the final follow-up plan sent by the medical side, so that the patient can understand the subsequent follow-up time.

[0102] In an optional embodiment, the disease management module is also used for online viewing of popular science knowledge, online consultation, appointment booking, and emergency calls.

[0103] Among them, the patient side uses the disease management module to realize the patient's online consultation, and the medical staff uses the online question and answer module to enable medical staff to answer the questions raised by patients online, establishing a real-time communication channel and providing emergency guidance. The disease management module on the patient side supports online viewing of popular science knowledge, provides disease-related knowledge education, and enhances the patient's self-management ability. In addition, the disease management module on the patient side supports emergency calls. By developing the first-level emergency call function, it can ensure that patients can quickly obtain medical assistance in unexpected situations.

[0104] In an optional embodiment, the patient end further includes:

[0105] The problem feedback module is used by patients to report their unpleasant experiences when using the disease management system; developers can further improve the system functions based on patient feedback to enhance the practicality and effectiveness of the system.

[0106] The task points module is used to display the pushed health tasks and record the relevant points after the patient completes the corresponding health tasks, so as to instruct the patient to use the points to obtain the corresponding rewards. In the embodiment of the present application, the points reward mechanism is used to encourage patients to actively complete the health tasks pushed by the system. Every time a patient completes a task, he or she can get corresponding points. Patients with high points ranking will enjoy the reward of exemption from follow-up registration fees, so as to further enhance the patient's participation and enthusiasm for health management.

[0107] In the embodiments of the present application, a convenient mobile interface is provided to patients on the patient side to realize functions such as popularization of professional knowledge, appointment booking and emergency call, which can meet the diversified needs of patients, form a one-stop management solution, and improve the self-management efficiency of patients with aortic dissection, thereby obtaining better disease management effects.

[0108] Based on the same principle as the method provided in the embodiment of the present application, the embodiment of the present application also provides a disease management method for patients with aortic dissection, which is implemented based on the above-mentioned disease management system for patients with aortic dissection. Figure 3 As shown, the method includes:

[0109] Step 301, collecting the patient's physiological data and recording relevant risk factors at the patient end;

[0110] Step 302, performing a survival risk assessment on the patient based on the physiological data and relevant risk factors on the mobile terminal to obtain a comprehensive score, and generating a personalized disease management strategy based on the comprehensive score;

[0111] Step 303, review and modify the personalized disease management strategy at the medical and nursing end to determine the final personalized disease management strategy.

[0112] In the embodiment of the present application, the patient end can collect the patient's physiological data and record relevant risk factors in real time. The mobile end evaluates the patient's survival risk based on the physiological data and relevant risk factors, obtains a comprehensive score, and generates a personalized disease management strategy based on the comprehensive score, which can achieve early warning and risk identification. The medical end reviews and modifies the personalized disease management strategy and determines the final personalized disease management strategy to ensure the professionalism and scientificity of the plan. The system in the embodiment of the present application evaluates the patient's physical condition so that the patient can have a clearer understanding of his or her own disease condition, and through the online guidance of medical staff, it can reduce health risks and improve the patient's quality of life. The system can provide a more comprehensive and personalized disease management plan for patients with aortic dissection.

[0113] The disease management method for patients with aortic dissection provided in the embodiment of the present application can achieve Figure 1 and Figure 2 To avoid repetition, the various modules implemented in the system embodiment are not described here.

[0114] The disease management method for patients with aortic dissection in the embodiments of the present application can realize the functions of the disease management system for patients with aortic dissection provided in the embodiments of the present application, and the implementation principles are similar. Each step in the disease management method for patients with aortic dissection in each embodiment of the present application corresponds to the actions performed by each module and unit in the disease management system for patients with aortic dissection in each embodiment of the present application. For the detailed functional description of each step of the disease management method for patients with aortic dissection, please refer to the description in the corresponding disease management system for patients with aortic dissection shown in the previous text, which will not be repeated here.

[0115] The above description is only a preferred embodiment of the present application and an explanation of the technical principles used. Those skilled in the art should understand that the scope of disclosure involved in the present application is not limited to the technical solution formed by a specific combination of the above technical features, but should also cover other technical solutions formed by any combination of the above technical features or their equivalent features without departing from the above disclosed concept. For example, the above features are replaced with the technical features with similar functions disclosed in this application (but not limited to) by each other to form a technical solution.

Claims

1. A disease management system for patients with aortic dissection, characterized in that: The system comprises: The patient side is used to collect the patient’s physiological data and record relevant risk factors; A mobile terminal, for evaluating the patient's survival risk based on the physiological data and the relevant risk factors, obtaining a comprehensive score, and generating a personalized disease management strategy based on the comprehensive score; The medical and nursing end is used to review and modify the personalized disease management strategy and determine the final personalized disease management strategy.

2. The disease management system for patients with aortic dissection according to claim 1, characterized in that: The physiological data includes basic information, physical sign data, movement data, psychological state change data, medication compliance and imaging data; The patient end includes: Basic information entry module, used to enter the patient's basic information; Vital sign monitoring module, used to collect vital sign data of patients; Lifestyle monitoring module, used to collect patients' vital signs and exercise data; The psychological status assessment module is used to collect data on changes in the patient's psychological status; Medication monitoring module, used to monitor patients' medication compliance; The imaging examination result module is used to collect imaging data of patients during follow-up.

3. The disease management system for patients with aortic dissection according to claim 2, characterized in that: The psychological state assessment module monitors the patient's psychological state change data based on galvanic skin response.

4. The disease management system for patients with aortic dissection according to claim 1, characterized in that: The mobile terminal comprises: A risk assessment module, used to analyze the physiological data and the relevant risk factors through a Cox proportional hazard model to obtain a comprehensive score for the patient; A risk stratification module, used to classify the comprehensive score according to a preset risk stratification standard to determine the patient's risk stratification level; A strategy generation module is used to generate a personalized disease management strategy based on the comprehensive score and the risk stratification level.

5. The disease management system for patients with aortic dissection according to claim 1, characterized in that: The personalized disease management strategy includes care plans, lifestyle recommendations, and follow-up plan recommendations; The medical end includes: A nursing plan guidance module is used to review and modify the nursing plan, convert various tasks and time nodes in the final nursing plan into reminders, obtain the final nursing plan, and send the final nursing items and reminders to the patient via a mobile terminal; A life habit guidance module, used for reviewing and modifying the life habit suggestions, obtaining final life habit suggestions, and sending the final life habit suggestions to the patient terminal via a mobile terminal; The follow-up plan guidance module is used to review and modify the follow-up plan suggestion, obtain the final follow-up plan, and send the final follow-up plan to the patient via the mobile terminal.

6. The disease management system for patients with aortic dissection according to claim 5, characterized in that: The patient end also includes a disease management module for viewing the final nursing plan, the final lifestyle recommendations and the final follow-up plan.

7. The disease management system for patients with aortic dissection according to claim 6, characterized in that: The disease management module is also used for online viewing of popular science knowledge, online consultation, appointment for medical treatment and emergency calls.

8. The disease management system for patients with aortic dissection according to claim 1 or 6, characterized in that: The patient end also includes: The problem feedback module is used by patients to report their unpleasant experiences when using the disease management system; The task points module is used to display pushed health tasks and record relevant points after the patient completes the corresponding health tasks, instructing the patient to use the points to obtain corresponding rewards.

9. The disease management system for patients with aortic dissection according to claim 5, characterized in that: The medical end also includes: The registration and login module is used to input the personal information of medical staff and assign corresponding system permissions; The online answer module is used by medical staff to answer questions raised by patients online.

10. A disease management method for patients with aortic dissection, implemented based on the disease management system for patients with aortic dissection according to any one of claims 1 to 9, characterized in that: The method comprises: Collect the patient's physiological data and record relevant risk factors at the patient end; Performing a survival risk assessment on the patient based on the physiological data and the relevant risk factors on the mobile terminal to obtain a comprehensive score, and generating a personalized disease management strategy based on the comprehensive score; The personalized disease management strategy is reviewed and modified at the medical and nursing end to determine the final personalized disease management strategy.

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