社区高血压控制:阶段目标管理的效果  

Hypertension control in community:the effects of stage goal management

作　　者：唐新华 金宏义 陈秉初 杨琳[3] 

机构地区：[1]浙江省心脑血管病防治研究中心浙江省老年病重点实验室,杭州310013 [2]杭州市朝晖社区卫生服务中心 [3]杭州市下城区卫生局

出　　处：《中华高血压杂志》2011年第3期231-235,共5页Chinese Journal of Hypertension

基　　金：浙江省科技重大专项(2008C03002-3)

摘　　要：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 hypertension management model in community.Methods One thousand three hundred eighteen patients with hypertension aged over 35 years were enrolled in this study.Eight hundred sixty-seven cases from one community were assigned to stage goal management group（A community）.Four hundred fifty-one cases from another community were assigned to general management group（B community）.In A community,a care manager was assigned and a series of disease management training was made.For cases in A community,cardiovascular risk was evaluate,an individual disease management program with stage goal was made and then it was performed in practice.Results Compared with the cases in B community,the mean blood pressure for cases in A community significantly decreased after 1 month management and fallen by 6.5/3.2 mm Hg after 6 months.The awareness,treatment and control rates of hypertension in A community significantly increased after 6 month＇s stage goal menagement（from 74.7% to 100%,from 79.6% to 91.1%,from 37.1% to 76.6%,respectively P0.01）.The rate of hypertension patients with smoking and drinking decreasded by 61.5% and 87.1% respectively,meanwhile the rate with salt intook6 g/d and physical exercise3 times/week increased by 63% and 34.8% respectively（P0.05）.97.5% patients were satisfied with the stage goal management and hoped it could be lasting for ever in A community.Conclusions The stage goal management for hypertension in community was benefit for not only the improving of the community medical staff ability,but also the patients compliance and blood pressure control rate.At the same time,the trust and satisfaction of community health service for inhabitant had been increased.

关 键 词：高血压 社区防治 阶段目标管理 疾病管理 

分 类 号：R544.1[医药卫生—心血管疾病]