医院-社区高血压管理模式在农村社区的初步探讨

目的 利用医院-社区高血压管理模式，探讨农村社区有效的慢性病健康管理模式。方法 将大理州湾桥社区卫生服务中心建立健康档案的所有高血压现症患者486例， 按照患者意愿分成3组，医院组166例， 自我干预组146例，社区干预组174例，实施一系列的干预措施并对3组干预前后结果进行评价。结果 干预后3组高血压知晓率、治疗率及控制率均有所提高，K、A、P平均得分和Mofisky评分均有所增加，其中医院组最高(P<0.05)。结论 在大理农村社区慢性病管理中，医院-社区管理模式成效显著，值得在其他社区推广。

Preliminary investigation of health management path of hypertension under the hospital community integrated management model in rural community

Objective To explore an effective health management mode of hypertension in rural community. Methods A total of 486 cases with hypertension in Wanqiao rural community were enrolled and divided into three groups， including hospital community group (166 cases)， self management group (146 cases) and self community group (174 cases). All three groups were comparatively analyzed after a series of interventions. Results There were significant increase in three groups in awareness rates of knowledge of hypertension， treatment rates and control rates after intervention. The K scores， A scores， P scores and Mofisky scores were increased after intervention， and the hospital community group had the highest score (P<0.05)． Conclusion Hospital community integrated management model can improve medication compliance in patients with hypertention，it was worth popularizing in other communities.