高血压"医院-社区-家庭"一体化全病程管理模式的构建与实证研究  

Construction and Empirical Study of“hospital-community-family”integrated whole course management model of hypertension

作　　者：杨露思 刘婷[1] 周彩虹 常子梦 崔嵘 Yang Lu-si;Liu Ting;Zhou Cai-hong;Chang Zi-meng;Cui Rong(Changsha Fourth Hospital Affiliated to Hunan Normal University,Changsha 410006,China)

机构地区：[1]湖南师范大学附属长沙市第四医院,长沙410006

出　　处：《湖南师范大学学报（医学版）》2022年第2期252-254,共3页Journal of Hunan Normal University(Medical Sciences)

基　　金：湖南省卫健委科研课题(202103010822)。

摘　　要：目的:探讨高血压的患者,构建及实施"医院-社区-家庭"一体化全病程管理模式的效果.方法:选取500例高血压患者分成干预组与对照组各250例,对照组采取门诊随访+常规治疗,干预组采取门诊随访+常规治疗+"医院-社区-家庭"三位一体化全病程管理模式,对各组随访6个月的血压控制情况及高血压治疗依从性促进与阻碍行为量表(FATS)评价.结果:干预组干预3个月与6个月的收缩压与舒张压均是低于对照组;干预组家庭血压控制率高于对照组;观察组干预后FATS各维度评分改善幅度比对照组显著.结论:采取"医院-社区-家庭"一体化全病程管理模式干预高血压对血压控制效果满意,提高患者依从性,减轻行为障碍.Objective To explore the effect of constructing and implementing the"hospital-community-family"integrated whole course management model for patients with hypertension.Methods 500 patients with hypertension were divided into intervention group and control group,with 250 cases in each group.The control group was treated with outpatient follow-up and routine treatment.The intervention group adopted the three integrated whole course management mode of outpatient follow-up+routine treatment+hospital community family.The blood pressure control and compliance promoting and hindering Behavior Scale(fats)of hypertension treatment were evaluated.Results The systolic and diastolic blood pressure of the intervention group at 3 and 6 months were lower than those of the control group;After the intervention,the improvement of the scores of all dimensions of fat in the observation group was significantly higher than that in the control group.Conclusion Taking the"hospital community family"integrated whole course management model to intervene hypertension has a satisfactory effect on blood pressure control,improve patient compliance and reduce behavioral disorders.

关 键 词：高血压 医院-社区-家庭 一体化 全程管理 血压控制 

分 类 号：R544.1[医药卫生—心血管疾病]