实施家庭医生服务对老年高血压患者血压相关因素的影响  

Influence of Implementation of Family Doctor Service on Factors Related to Blood Pressure in Elderly Hypertensive Patients

作　　者：裴宇慧[1] 曾彩云[1] 石建新[1] 卢玩弟[1] 王丹[1] 巩小瑞[1] 秦川[1] 赵云鹏[2] 

机构地区：[1]广东省深圳市福田区慢性病防治院金地社区健康服务中心,518048 [2]深圳市福田区慢性病防治院

出　　处：《中国全科医学》2012年第36期4240-4242,共3页Chinese General Practice

摘　　要：目的分析家庭医生服务对老年高血压患者血压相关因素的影响。方法选取2011年10月与本社区健康服务中心签订家庭医生服务协议的老年高血压患者60例,由家庭医生服务团队为其提供健康评估、健康干预并追踪管理的健康管理项目,为期10个月。对比实施家庭医生服务前后与老年高血压患者血压相关的8个因素〔高血压相关知识知晓率、自我管理能力、治疗依从性、随访情况、降压药品比、血压控制率、人均随访工作量及缺血性心血管病(ICVD)10年发病危险评估〕变化情况。结果实施家庭医生服务后,老年高血压患者的高血压相关知识(包括高血压诊断标准、高血压危害、高危因素、预防知识)知晓率、自我管理能力(包括了解自己目前血压、达到自身运动量、食盐摄入达标、能自我控制情绪)较实施前提高,差异均有统计学意义(P<0.05);在降压药品比(7.24%与7.47%)变化幅度不大的情况下,老年高血压患者治疗依从性、随访情况与实施家庭医生服务前比较,差异均有统计学意义(P<0.05);医护人员为老年高血压患者提供随访的人均工作量为34人次/月,较实施前的237人次/月降低;高血压控制率及ICVD 10年发病绝对危险程度比较,差异均无统计学意义(P>0.05)。结论家庭医生服务显示出了对老年高血压患者血压控制的积极影响。应进一步对家庭医生服务追踪研究,增加样本数量及延长观察时间。Objective To analyze the influence of family doctor service on factors related to blood pressure in elderly hypertensive patients. Methods 60 senior hypertensive patients who signed family doctor service agreement with the health center in October 2011 were selected. Family doctors performed health assessment, health intervention and tracking and managing serv- ices for the patients for ten months. Factors related to blood pressure （ hypertension related knowledge awareness, self manage- ment ability, treatment compliance, follow- up, antihypertensive drug proportion, blood pressure control, the average follow- ing up performed by each doctor, next 10 years ICVD disease risk assessment） were compared before and after the serv- ices. Results After the implementation of family doctor service, the patients＇ awareness rate about hypertension related knowl- edge （ including hypertension diagnosing criteria, harm of hypertension, high risk factors and prevention knowledge） and self - management ability （ including the understanding of current blood pressure, meeting exercise target, standard salt intake and self - emotion control） were significantly improved （ P 〈 0. 05 ） . Under the circumstances that antihypertensive drug proportion hav- ing no obvious changes, the treatment compliance and follow up after the implementation of family doctor service showed statisti- cally significant differences （P 〈 0. 05 ） . The average following up performed by each doctor was 34 person - time/month, lower than that before the implementation ; hypertension control rate and ten - year ICVD risk showed no statistically significant differ- ences compared with those before the implementation （P 〉 0.05 ） . Conclusion The family doctor service has positive impact on blood pressure control among senior hypertensive patients. We should make further research on family doctor service by increasing sample quantity and extending the observation time.

关 键 词：高血压 老年人 家庭医生服务 

分 类 号：R544.1[医药卫生—心血管疾病]