三级医院多学科综合管理团队联动社区药师的老年高血压患者管理模式研究  

Study on the management model of elderly patients with hypertension by multi-disciplinary comprehensive management team of tertiary hospital collaborated with community pharmacists

作　　者：韩丹 聂力[1] 王美华 吴金丽 严思敏 李伏超 钱云 郗有丽 HAN Dan;NIE Li;WANG Meihua;WU Jinli;YAN Simin;LI Fuchao;QIAN Yun;XI Youli(Dept.ofPharmacy,Drum Tower Hospital,the Affiliated Hospital of Nanjing University Medical School,Nanjing210008,China;Dept.of Pharmacy,Yuhua Community Health Service Center of Nanjing,Nanjing 210012,China;Dept.of Gerontology,Drum Tower Hospital,the Affiliated Hospital of Nanjing University MedicalSchool,Nanjing 210008,China;Dept.of Dermatology,Institute of Dermatology,Hospital of Dermatology,Chinese Academy of Medical Science,Nanjing 210008,China)

机构地区：[1]南京大学医学院附属鼓楼医院药学部,南京210008 [2]南京市雨花社区卫生服务中心药剂科,南京210012 [3]南京大学医学院附属鼓楼医院老年医学科,南京210008 [4]中国医学科学院皮肤病医院皮肤病研究所皮肤外科,南京210008

出　　处：《中国药房》2024年第16期2033-2037,共5页China Pharmacy

基　　金：南京大学现代医院管理与发展研究所课题(No.NDYG2021049);江苏省药学会-恒瑞医院药学基金科研项目(No.H202154,No.H202020);南京药学会-常州四药医院药学科研基金项目(No.2020YX008);南京大学医学院附属鼓楼医院中西医协同特色技术发展项目(No.CZXM2022110)。

摘　　要：目的探讨三级医院多学科综合管理团队(简称“综合管理团队”)联动社区卫生服务机构的药师(简称“社区药师”)对社区老年高血压患者的管理模式及实施效果。方法选择2020年5月-2021年5月于南京市雨花社区卫生服务中心就诊的老年高血压患者,根据管理方式不同分为对照组(76例)和观察组(76例),分别接受社区医院的常规诊疗服务和常规诊疗服务+综合管理团队联动社区药师的药学服务。比较两组患者接受干预前及干预后24个月的治疗依从性、血压控制情况以及高血压相关并发症发生情况。结果干预24个月后,两组患者的依从性和血压达标率均高于干预前,且观察组显著高于同期对照组(P<0.05或P<0.01);两组患者的血压水平均显著低于干预前,观察组患者的收缩压水平和所有并发症、脑血管损害发生率均显著低于同期对照组(P<0.05)。患者血压达标情况对并发症的影响具有统计学意义(P<0.01)。结论综合管理团队联动社区药师的高血压管理模式能显著提高老年高血压患者的依从性及血压达标率,并降低高血压相关并发症的发生率。OBJECTIVE To explore the effects of multi-disciplinary comprehensive management team of tertiary hospital collaborated with the pharmacists from community health service center(hereinafter referred to as“community pharmacists”)on elderly patients with hypertension in the community.METHODS Elderly patients with hypertension from May 2020 to May 2021 in Yuhua Community Health Service Center of Nanjing were divided into control group(76 cases)and observation group(76 cases)according to the management style.The control group was treated with regular community medical services and the observation group received regular community medical services plus pharmaceutical care provided by the comprehensive management team collaborated with community pharmacists.The compliance,blood pressure control status and hypertension-related complications were compared between 2 groups before management and after 24 months of management.RESULTS After 24 months of management,the compliance and blood pressure compliance rates in both groups were higher than before management;meanwhile,the observation group was significantly higher than control group at the corresponding period(P<0.05 or P<0.01).The blood pressure levels of both groups were significantly lower than before management,and the systolic blood pressure as well as the incidences of the whole complications and cerebrovascular injury in the observation group were significantly lower than control group at the corresponding period(P<0.05).There was statistical significance in the effects of the rate of reaching the standard of blood pressure on the complications(P<0.01).CONCLUSIONS The hypertension management mode of comprehensive management team collaborated with community pharmacists can significantly improve the compliance and blood pressure compliance rate of elderly patients with hypertension,and reduce the incidence of hypertension-related complications.

关 键 词：高血压 多学科综合管理 社区药师 依从性 

分 类 号：R95[医药卫生—药学] R544.1