基于电子健康档案的上海市家庭医生在管高血压患者共病模式研究  

Study on comorbid pattern in hypertension patients managed by Shanghai family doctors based on electronic health records

作　　者：李丽平 赵蕴珊 田娟娟 彭洪 林森林 贾英男[2] 傅华[2] 王飞[1] 叶景虹[1] LI liping;ZHAO Yunshan;TIAN Juanjuan;PENG Hong;LIN Senlin;JIA Yingnan;FU Hua;WANG Fei;YE Jinghong(Shanghai Hongkou District Center for Disease Control and Prevention(Shanghai Hongkou District Health Supervision Institute),Shanghai 200082,China;不详)

机构地区：[1]上海市虹口区疾病预防控制中心(上海市虹口区卫生健康监督所),上海200082 [2]复旦大学公共卫生学院,上海200030 [3]上海市眼病防治中心,上海200041

出　　处：《中华全科医学》2025年第5期746-749,共4页Chinese Journal of General Practice

基　　金：上海市加强公共卫生体系建设三年行动计划(2023-2025年)优秀青年人才项目(GWVI-11.2-YQ56);2023年上海市虹口区卫生健康委员会医学科研课题重大项目(虹卫2301-06);上海市卫生健康委员会政策研究(自选)课题(2024HP44)。

摘　　要：目的 分析上海市家庭医生在管高血压患者多病情况和共病模式,为高血压患者精准管理提供理论依据。方法 基于慢性病一体化管理系统,选取上海市虹口区2016年10月—2023年12月的99 531例家庭医生在管高血压患者诊疗数据,通过Apriori算法和聚类分析,探索多病共存情况和共病模式,并使用Web图可视化慢性病间的非随机关联。结果 上海市家庭医生在管高血压患者共病的比例为93.93%(92 201例),女性高于男性、高年龄组高于低年龄组(P<0.001)。高血压共病数量集中在2~6种,占总数的76.00%(74 602例);关联挖掘得到12条强关联规则,高血压患者中脑卒中、肾脏疾病、心脏病、糖尿病、慢性肺部疾病、关节炎或风湿病处于主要地位。其主要的多重共病模式共有51 710人,该模式病发生比例较高的前3位为心脏病50 185人(97.05%),关节炎或风湿病36 250人(70.10%)和慢性肺部疾病31 590人(61.09%)。结论 本研究提示对社区纳管高血压群体加强整合型慢性病管理指导的重要性,为高血压社区管理考核指标的改善、共病组合治疗和合并症健康管理提供了参考。Objective To analyze the multimorbidity and comorbidity patterns among hypertensive patients managed by family doctors in Shanghai,and to provide a theoretical basis for the precise management of hypertensive patients.Methods Based on the chronic disease integration management system,this study included 99531 hypertensive patients managed by family doctors in Hongkou District,Shanghai,from October 2016 to December 2023.The Apriori algorithm and cluster analysis were used to explore the multimorbidity and comorbidity patterns,while the Web graph was used to visualize the non-random associations among chronic diseases.Results The proportion of hypertensive patients managed by family doctors in Shanghai was 93.93%(92201 cases),with higher rates observed in women and older age groups(P<0.001).A total of 76.00%(74602 cases)patients had 2 to 6 comorbid conditions.Association rule mining showed that 12 strong association rules,primarily involving stroke,kidney disease,heart disease,diabetes disease,chronic lung disease,arthritis or rheumatism.There were 51710 people in the main comorbidity pattern,and the top 3 patterns with higher incidence were:heart disease 50185 people(97.05%),arthritis or rheumatism 36250 people(70.10%),and chronic lung disease 31590 people(61.09%).Conclusion The study highlights the importance of strengthening integrated chronic disease management for the community-based hypertension group.The study provides a reference for the improvement of assessment indicators in community management of hypertension,combination treatment of comorbidities and health management of comorbidities.

关 键 词：高血压 关联规则 多病共存 共病模式 

分 类 号：R544.1[医药卫生—心血管疾病]