论文部分内容阅读
目的探索高血压社区疾病管理的模式。方法选择二个社区35岁以上高血压人群1318例,分别入组阶段目标管理社区(A社区,867例)和一般管理社区(B社区,451例);A社区设置疾病管理责任师,并进行疾病管理系列知识培训;对入选的高血压患者进行心血管危险评估,制定个体化疾病管理计划;设定阶段干预目标,并逐步实施。结果 A社区高血压患者在管理1月后平均血压明显下降,并持续保持到第6月(平均收缩压下降6.5mmHg,舒张压下降3.2mmHg),与B社区比较差异有统计学意义(P<0.05)。6月后A社区高血压知晓率、治疗率和控制率分别由74.7%、79.6%、37.1%提高到100%、91.1%、76.6%,明显好于B社区(均P<0.01);A社区高血压患者吸烟、饮酒量减少人数分别达61.5%、87.1%。A社区每日食盐<6g人数增加了63%,一周运动>3次的人数增加了34.8%。与B社区人群比较差异有统计学意义(P<0.01)。A社区97.5%的患者对阶段目标管理表示满意,并希望能长期实施。结论社区高血压阶段目标管理不仅可迅速提高社区对高血压患者管理水平,尤其适合基层医生为社区高血压患者制定个体目标管理计划和逐步实施;而且大大提高高血压患者的治疗依从性及血压达标率,改变不良生活方式;同时提升了社区居民对社区卫生服务的信任和满意程度。
Objective To explore the mode of hypertension community disease management. Methods A total of 1318 hypertensive patients over the age of 35 were enrolled in the two community-based interventions, including target management community (A community, 867 cases) and general management community (B community, 451 cases) in group A; community A disease management responsibility division A series of knowledge on disease management training; Cardiovascular risk assessment of selected hypertensive patients, development of individualized disease management plans; Set targets for phase intervention and phased implementation. Results The average blood pressure of community-based hypertensive patients in community A decreased significantly after 1 month of management and persisted till the 6th month (mean systolic blood pressure decreased 6.5mmHg and diastolic blood pressure decreased 3.2mmHg), which was significantly different from that of community B (P < 0.05). The community-based hypertension awareness rate, treatment rate and control rate in community A increased from 74.7%, 79.6% and 37.1% to 100%, 91.1% and 76.6% respectively after 6 months, which were significantly better than those in community B (all P <0.01) Hypertensive patients smoking, alcohol consumption decreased by 61.5%, 87.1%. A community daily salt <6g 63% increase in the number of people, a week exercise> 3 times the number increased 34.8%. Compared with B community, the difference was statistically significant (P <0.01). 97.5% of patients in community A are satisfied with the management of phase goals and hope to implement them in the long term. Conclusion Objective management of community hypertension stage can not only rapidly improve the community management of patients with hypertension, especially for grassroots doctors to develop individual target management plan for community-based hypertensive patients and gradually implement; and greatly improve the compliance of patients with hypertension and blood pressure compliance Rate, change unhealthy lifestyles; at the same time enhance community residents’ trust and satisfaction with community health services.