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目的:探讨高血压合并高脂血症患者应用社区责任医师团队细节化管理的效果。方法:选取2012年6月至2013年12月与杭州市下城区朝晖街道社区责任医师团队签约的100例高血压合并高脂血症患者作为研究对象,2013年1月至12月对此100例患者实施社区责任医师团队细节化管理,即在社区责任医师团队管理的基础上增加细节化管理,比较管理前和管理后患者血压、血脂、饮食、运动、心理平衡及药物治疗等改善情况。结果:实施社区团队细节化实施管理后,患者行为、知识掌握、血压及血脂水平均有明显改变,患者总满意率明显提高。结论:社区责任医师团队细节化管理模式可有效提高高血压合并高脂血症患者对疾病相关知识掌握度,患者用药与饮食等均更为规律,在血压、血脂、及体重控制上也更为有效。
Objective: To investigate the effect of using community-based responsible physician team’s detailed management in hypertensive patients with hyperlipidemia. Methods: From June 2012 to December 2013, 100 hypertensive patients with hyperlipidemia who contracted with community responsibility physician team of Zhaohui Street community in Xiacheng District of Hangzhou City were enrolled in this study. From January to December in 2013, 100 cases Patients implemented a community-based management team with detailed management, which included adding detailed management based on the management of community-responsible physician teams and comparing the improvement of patients’ blood pressure, blood fat, diet, exercise, psychological balance and drug treatment before and after management. Results: After implementing the detailed implementation and management of community team, patient behavior, knowledge, blood pressure and blood lipid levels were significantly changed, and the overall satisfaction rate of patients significantly increased. Conclusion: The community-based management team can effectively improve the mastery of disease-related knowledge, medication and diet in patients with hypertension and hyperlipidemia, and more in blood pressure, blood lipid and weight control effective.