| 吕岩玉,李子贵,王利红,肖峰,刘颖,武阳丰,王增武,谢晓桦,樊朝阳,孙谨芳,汪关宝,陈博文.北京市中关村社区高血压病例管理方案实施效果评价[J].Chinese journal of Epidemiology,2005,26(6):400-403 |
| 北京市中关村社区高血压病例管理方案实施效果评价 |
| Evaluation on the case management program of hypertension in Zhongguancun community, Beijing |
| Received:October 29, 2004 |
| DOI： |
| KeyWord: 高血压 病例管理 社区卫生服务 随访 |
| English Key Word: Hypertension Case management Community health service Follow up |
| FundProject:加拿大国际发展研究中心基金资助项目(97022501/02857) |
| Author Name | Affiliation | E-mail | | LV Yan-yu | Department of Health Development, Capital Institute of Pediatrics, Beijing, 100020, China | | | LI Zi-gui | Department of Health Development, Capital Institute of Pediatrics, Beijing, 100020, China | | | WANG Li-hong | Department of Health Development, Capital Institute of Pediatrics, Beijing, 100020, China | | | XIAO Feng | Department of Health Development, Capital Institute of Pediatrics, Beijing, 100020, China | | | LIU Ying | 北京市中关村社区卫生服务中心 | | | WU Yang-feng | 中国医学科学院阜外心血管病医院流行病学研究室 | | | WANG Zeng-wu | 中国医学科学院阜外心血管病医院流行病学研究室 | | | XIE Xiao-hua | Department of Health Development, Capital Institute of Pediatrics, Beijing, 100020, China | | | FAN Zhao-yang | Department of Health Development, Capital Institute of Pediatrics, Beijing, 100020, China | | | SUN Jin-fang | 山西医科大学公共卫生学院 | | | WANG Guan-bao | 北京市中关村社区卫生服务中心 | | | CHEN Bo-wen | Department of Health Development, Capital Institute of Pediatrics, Beijing, 100020, China | bowenc@126.com |
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| Abstract: |
| 目的探索适合社区应用的、规范有效的高血压病例管理方案。方法采取以正常血压值为管理目标,以《中国高血压防治指南》为指导的社区高血压病例管理方案,对中关村社区卫生服务中心567例签约的高血压患者进行随访研究。结果6个月后,高血压患者的血压控制率明显上升(P<0.0001),由原来的50.44%上升到69.84%,整体血压水平显著下降(P<0.0001),收缩压(SBP)下降了3.72mmHg(1mmHg=0.133kPa),舒张压(DBP)下降了2.67mmHg,基线血压异常者SBP下降了8.59mmHg,DBP下降了5.26mmHg。患者的危险行为如吸烟、食盐过多、不参加体育锻炼的比例明显下降(P<0.05)。家庭医生对患者6个月内人均随访次数为7.69次±2.37次,按要求随访患者的血压控制率明显高于不按要求随访患者的血压控制率(P<0.0001),随年龄、文化程度的增高按时随访率有升高趋势(P<0.001)。结论社区卫生服务机构实施的高血压病例管理方案,对提高社区患者的血压控制率是一种有效的管理模式,患者按照家庭医生的要求随访有利于血压控制。 |
| English Abstract: |
| Objective To explore a suitable model regarding community2based case management of hypertension in the urban areas. Methods Based on the guidelines set by the Chinese Hypertension League (CHL), the goal of case management of hypertension was set as:to maintain blood pressure at the normal range. Family doctors were guided to take care of case management. Hypertension patients who had been contracted to the family doctors were followed by a team of family doctors for half a year. Results After the 62month intervention, the rate of hypertension under control had increased from 50. 44% to 69.84%(P<0.0001) while the means of systolic blood pressure decreased by 3.72 mm Hg and diastolic blood pressure decreased by 2.67 mm Hg (P<0.0001) respectively. The means of SBP decreased by 8.59 mm Hg and diastolic blood pressure decreased by 5. 26 mm Hg in patients whose baseline blood pressure were not under control. The rates of smoking, higher salt intake and no physical exercise had significantly decreased(P<0.05). The mean number of hospital visits in the six2month follow2up period was 7.69 ±2.37. The“rate of control”among those who had followed schedule was higher than that of those who were not on schedule (P<0.0001). The rate among those who had followed the schedule tended to have increased with aging and the level of education (P<0.001). Conclusion The community2based case management program on hypertension played an important and effective role in the control of hypertension in urban areas. Patients received great benefit when following the guidance from their doctors. |
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