二级医院联合社区一体化管理对高血压治疗的研究  

The Research about Secondary Hospitals United Community Integrated Management of Hypertension Treatment

作　　者：杨婉花[1] 刘鸿翔[1] 刘景全[1] 万晟霞[1] 王彩红[1] 

机构地区：[1]上海交通大学附属第一人民医院松江分院心内科,上海市201600

出　　处：《中华全科医学》2013年第10期1604-1605,共2页Chinese Journal of General Practice

摘　　要：目的摸索适合农村社区的创新的二级医院联合社区对高血压综合干预管理模式及其效果。方法回顾医改2009—2011年，二级医院联合农村社区对高血压患者实行的建档随访、健康教育、饮食、运动及行为干预、合理用药等综合措施后管理干预，并对部分高危极高危患者的靶器官之一心脏左室重量指数的基线和随访3年后的指标的记录及对比。结果控制率由2009年的51．11％增加到2011年的61．35％；脑血管病病死率呈下降趋势，由2009年的120．61／10万下降到2011年的100／10万（P〈0．01）。高危和极高危患者的血压达标与未达标组的左室重量指数，达标基线（123．6±35．3）g／m^2，末次（119．5±37．8）g／m^2（P〈0．01）；未达标基线（130．8±40．5）m^2，末次（136．5±54．1）g／m^2，无明显差异（P〉0．01）。结论二级医院社区一体化高血压管理在农村社区实施是可行、有效的，但需进一步完善。Objective To explore an innovative comprehensive intervention management model of rural community hypertension and effectiveness. Methods The management intervention effect after applied a measure of create a file and follow-up, health education, diet and exercise, and behavioral intervention, rational drug use for patients with hypertension in the model of secondary hospitals united community integrated management were reviewed when health care reform from 2009 to 2011. Then se- lect cardiac as one of the target organs in high risk and very high risk patients, to calendar left ventricular mass index baseline and compare with the data after follow-up of three years. Results The control rate increased from 51.11% （2009） to 61.35% （ 2011 ） ; cerebrovascular disease mortality showed a downward trend that from 120.61/100 thousand to 100/100 thousand （ P 〈 0.01 ）. Statistical results showed that the standard baseline of the left ventricular mass index in blood pressure standards and non- attainment group of high-risk and very high-risk patients was （ 123.6 ± 35.3 ） g/m^2 ;last was （ 119.5 ± 37.8 ） g/m^2 （ P 〈 0.01 ）, and non-attainment baseline was （ 130.8 ± 40.5 ） g/m^2 ; and last was （ 136.5 ± 54.1 ） g/m^2, there was no significant difference （ P 〉 0.01 ）. Conclusion Secondary hospital community integration hypertension management in rural communities was feasible and effective, but need to be further improved.

关 键 词：高血压 一体化综合管理 效果回顾 

分 类 号：R544.1[医药卫生—心血管疾病] R197.6[医药卫生—内科学]