论文部分内容阅读
目的探索适合社区应用的、规范有效的高血压病例管理方案。方法采取以正常血压值为管理目标,以《中国高血压防治指南》为指导的社区高血压病例管理方案,对中关村社区卫生服务中心567例签约的高血压患者进行随访研究。结果6个月后,高血压患者的血压控制率明显上升(P<0.0001),由原来的50.44%上升到69.84%,整体血压水平显著下降(P<0.0001),收缩压(SBP)下降了3.72mmHg(1mmHg=0.133kPa),舒张压(DBP)下降了2.67mmHg,基线血压异常者SBP下降了8.59mmHg,DBP下降了5.26mmHg。患者的危险行为如吸烟、食盐过多、不参加体育锻炼的比例明显下降(P<0.05)。家庭医生对患者6个月内人均随访次数为7.69次±2.37次,按要求随访患者的血压控制率明显高于不按要求随访患者的血压控制率(P<0.0001),随年龄、文化程度的增高按时随访率有升高趋势(P<0.001)。结论社区卫生服务机构实施的高血压病例管理方案,对提高社区患者的血压控制率是一种有效的管理模式,患者按照家庭医生的要求随访有利于血压控制。
Objective To explore a standardized and effective hypertensive case management plan suitable for community application. Methods Taking the normal blood pressure value as the management target and taking the guideline of prevention and treatment of hypertension in China as the guideline of community hypertension management program, 567 contracted hypertensive patients in Zhongguancun Community Health Service Center were followed up. Results After 6 months, the rate of blood pressure control in hypertensive patients increased significantly from 50.44% to 69.84% (P <0.0001), the overall blood pressure decreased significantly (P <0.0001) and systolic blood pressure (SBP) decreased 3.72 mmHg (1 mmHg = 0.133 kPa), DBP decreased by 2.67 mmHg, SBP decreased by 8.59 mmHg, and DBP decreased by 5.26 mmHg at baseline. The dangerous behavior of patients such as smoking, excessive salt, not participating in physical exercise decreased significantly (P <0.05). The average number of follow-up visits by family doctors to patients was 7.69 ± 2.37 times within 6 months. The rate of blood pressure control was significantly higher in patients with follow-up visits than those who did not follow-up visits (P <0.0001) Increased on-time follow-up rates have increased (P <0.001). Conclusion Hypertensive management programs implemented by community health service institutions are an effective management mode to improve blood pressure control rate in community patients. Follow-up of patients with family doctors is beneficial to blood pressure control.