基于路径化和信息化的医院社区一体化高血压病管理  

Clinical pathway and Informationization-based integrated hospital-community hypertension management

作　　者：郑跃[1] 赵费敏[2] 程震锋[3] 黄立新 陆奇慧 杨峰 崔帆 ZHENG Yue;ZHAO Feimin;CHENG Zhenfeng;HUANG Lixin;LU Qihui;YANG Feng;CUI Fan(Department of General practice and Emergency Department,Huzhou Centre Hospital,Affiliated Centre Hospital HuZhou University,Huzhou 313000,China)

机构地区：[1]湖州市中心医院(湖州师范学院附属中心医院)急诊科,313000 [2]湖州市中心医院(湖州师范学院附属中心医院)全科,313000 [3]湖州市中心医院(湖州师范学院附属中心医院)心内科,313000 [4]湖州市中心医院医疗保健集团龙溪院区全科 [5]月河飞英院区全科

出　　处：《心电与循环》2020年第6期581-586,共6页Journal of Electrocardiology and Circulation

基　　金：湖州市科学技术局公益性技术应用研究项目(2018GYB24)。

摘　　要：目的评价路径化和信息化的医院社区一体化高血压慢病管理效果及对社区医师专业能力的影响。方法于2018年12月选择2个条件相匹配社区,其中1个为观察组,实施基于路径化和信息化的医院社区一体化高血压慢病管理;1个社区为对照组,进行常规社区医院高血压慢病管理,12个月后比较社区高血压达标率、治疗依从性评分以及社区医师对高血压诊治知识的掌握情况。结果观察组高血压达标率(77.51%)和治疗依从性评分[(103.40±3.96)分]均高于对照组[63.31%、(100.08±3.84)分],差异均有统计学意义(均P<0.05)。观察组患者空腹血糖、甘油三酯、低密度脂蛋白胆固醇、尿酸、同型半胱氨酸达标情况均优于对照组,差异均有统计学意义(均P<0.05)。观察组社区医师的高血压防治基础知识和诊治水平评分[(59.96±1.99)分、(26.00±0.76)分]均高于对照组(48.62±3.09)分、(24.67±0.80)分],差异均有统计学意义(均P<0.01)。结论基于路径化和信息化的医院社区一体化管理模式能改善社区高血压防治效果,提高社区医师专业水平。Objective To evaluate the efficacy of integrated hospital-community hypertension management based on clinical pathway and informationization and its effect on physician professional ability.Methods Two community clinics with conditions-matched were selected in December 2018.One was assigned as experience group and another as control group.The clinical pathway and informationization-based integrated hospital-community hypertension management were implemented in experience group and routine community care were implemented in control group.Hypertension control rate,treatment adherence scale and community physician knowledge of hypertension diagnosis and treatment were compared between the two groups 12 months later.Results Hypertension control rate and adherence scale were significantly higher in experience group(77.51%,103.40±3.96)than in control group(63.31%,100.08±3.84)(all P<0.05).The control rates of fasting blood glucose,triglycerides,low-density lipoprotein cholesterol,uric acid and homocysteine were significantly higher in experience group than in control group(all P<0.05).The scores of physician knowledge and ability in the diagnosis and treatment of hypertension were significantly higher in experience group than in control group[59.96±1.99 vs.48.62±3.09,26.00±0.76 vs.24.67±0.80,respectively,all P<0.05].Conclusion The clinical pathway and informationization-based integrated hospital-community hypertension management model can improve the prevention and treatment of hypertension in community as well as physician professional ability.

关 键 词：高血压 临床路径 信息化 依从性 

分 类 号：R544.1[医药卫生—心血管疾病]