家庭医生双签约管理模式在社区老年高血压患者健康管理中的应用效果观察  

Observation on the application effect of family doctor double contract management mode in the health management of elderly patients with hypertension in community

作　　者：刘闻莺 黄苏敏 瞿怡倩 杨楠 LIU Wenying;HUANG Sumin;QU Yiqian;YANG Nan(Department of General Practice,Zhenru Community Health Service Center of Putuo District,Shanghai 200333,China)

机构地区：[1]上海市普陀区真如镇街道社区卫生服务中心全科医学科,上海200333

出　　处：《医药前沿》2025年第12期140-143,共4页Journal of Frontiers of Medicine

摘　　要：目的观察家庭医生双签约管理模式对社区老年高血压患者血压水平、服药依从性情况与自测健康评定的影响。方法收集2021年8月—2022年7月上海市普陀区真如镇街道社区卫生服务中心就诊的老年高血压患者200例,根据是否接受家庭医生双签约管理分成观察组和对照组各100例。两组患者均进行健康宣教,对照组采用常规管理模式,患者每季度随访1次;观察组采用家庭医生双签约管理模式,患者由家庭医生团队督促患者每周监测血压1次,每2个月随访1次,签约专家每季度开展健康咨询活动。观察两组患者服药依从性、血压水平、自测健康评定与血压控制情况。结果两组入组时及入组6、12个月收缩压、舒张压水平、自测健康评定总分比较,差异无统计学意义(P>0.05)。两组入组时及入组6个月Morisky评分比较,差异无统计学意义(P>0.05);入组12个月,观察组Morisky评分高于对照组(P<0.05)。入组12个月,观察组血压控制率略高于对照组,但差异无统计学意义(P>0.05)。结论家庭医生双签约管理模式一定程度上可以提高老年高血压患者服药依从性,提升血压控制率。Objective To observe the effect of family doctor double contract management mode on blood pressure level,medication compliance and self-test health assessment of elderly patients with hypertension in community.Methods From August 2021 to July 2022,a total of 200 elderly patients with hypertension were collected from Zhenru Community Health Service Center of Putuo District,Shanghai according to whether they received family doctor double contract management mode,they were divided into observation group and control group,with 100 cases in each group.Patients in both groups were given health education,the control group was treated with routine management mode,and the patients were followed up once a quarter;the observation group adopted family doctor double contract management mode,the patients were urged by the family doctor team to monitor blood pressure once a week,followed up once every 2 months,and contracted experts carried out health consultation activities every quarter.The medication compliance,blood pressure level,self-rated health assessment and blood pressure control of the two groups were observed.Results There was no significant difference in systolic blood pressure,diastolic blood pressure and total score of selfrated health assessment between the two groups at 6 and 12 months after enrollment(P>0.05).There was no significant difference in Morisky score between the two groups at the time of enrollment and 6 months after enrollment(P>0.05);after 12 months of enrollment,the Morisky score of the observation group was higher than that of the control group,and the difference was statistically significant(P<0.05).After 12 months of enrollment,the blood pressure control rate of the observation group was slightly higher than that of the control group,but there was no significant difference between the two groups(P>0.05).Conclusions Family doctor double contract management mode can improve the medication compliance and blood pressure control rate of elderly patients with hypertension to a certain extent.

关 键 词：家庭医生双签约管理模式 老年人 高血压 服药依从性 血压控制率 

分 类 号：R544[医药卫生—心血管疾病]