“合作管理”模式对社区高血压患者综合干预的效果评估

目的通过“合作管理”模式探讨对社区高血压患者进行综合干预的效果,为今后在社区中开展高血压防治与管理工作提供指导。方法在北京市西城区复兴医院社区中,按照随机抽样方法选取401例高血压病患者,由社区卫生服务站的全科医生对其实施一对一的互动式“合作管理”模式,包括提供健康教育、戒烟、减重、平衡膳食、有氧运动、心理调试等非药物治疗及合理用药治疗等综合干预的措施,每月定期随访,为期一年。结果采用“合作管理”模式干预后较干预前,高血压患者服药依从性提高了17.0%（P〈0.01）。高血压患者在限盐、运动、减肥、知晓血压值等方面分别提高了19.8%、11.9%、21.1%和14.2%（P〈0.01）。在控酒和戒烟方面略有提高,但差异不明显。高血压患者血压控制良好的比例干预后比干预前增加了34.1%,有统计学差异。在老年组高血压患者中家族史、高血脂、糖尿病及肥胖危险因素较对照组有统计学差异。结论“合作管理”模式在社区高血压病的综合干预防治的工作中取得了良好效果,是有效、可行的。

Effect evaluation of the collaborate management mode in comprehensive intervention among hypertension patients in community

Objective To evaluate the effects of the collaborate management mode in comprehensive intervention among patients with hypertension in community,and to provide reference for further prevention and control of hypertension in community.Methods Collaborate management,including health education,smoking cessation,weight reducing,balanced diet,aerobic exercise,psychological adjustment,etc.was conducted among 401 hypertension patients that random selected from Fuxing Hospital in communities of Xicheng District in Beijing,as comprehensive intervention measures by the general practitioners of community health service stations with one-to-one model.Every month follow-up lasted 1 year.Results After the intervention of collaborate management,drug-taking compliance of hypertension patients increased by 17.0%(P<0.01).The rate of salt restriction,exercise,weight reducing and blood pressure awareness increased by 19.8%,11.9%,21.1% and 14.2% respectively(P<0.01).The rate of wine control and smoking cessation increased a little,with no statistical difference.The percentage of well-controlled blood pressure increased by 34.1%,with a statistical difference.Conclusion Collaborate management model is effective and feasible in comprehensive intervention among hypertension intervention in community.