社区高血压患者精细化管理临床效果评价

目的：在高血压规范化管理基础上进一步进行精细化管理，评价精细化管理效果。方法：利用我区社区卫生全部应用电子化病例等电子化系统，回顾性观察分析东四社区卫生站所管辖的200名原发性高血压患者。分为两组，其中1组100名高血压患者，自2010年以来全科医生每月对其进行至少1次面对面的随访，进行生活方式等非药物及药物治疗等综合干预的精细化管理两年，另1组100名高血压患者进行每年至少4次面对面的随访一般管理。比较两组高血压患者的管理效果，血压控制率。结果：高血压精细化管理组血压控制率100％，两年随访诊室收缩压（SBP）平均（128．51±11．42）mmHg，舒张压（DBP）平均（74．89±7．28）mmHg；一般管理组血压控制率86％，两年随访诊室收缩压平均（131．16±12．64）mmHg，舒张压平均（76．20±9．79）mmHg，两组三项指标差异具有统计学意义；一般管理组和精细化管理组干预后收缩压、舒张压均较前改善，具有统计学意义。结论：精细化管理高血压患者临床效果好，血压控制的达标率高，值得推广。

Clinical effect evaluation of delicacy management for hypertension patients in community

Objective：Based on the standardization management of high blood pressure, to carry out delicacy management and evaluate its effects. Methods： By using electronic systems like electronic medical records, 200 cases with essential hypertension charged by Dongsi community station grassroots clinics were divided into two groups with 100 cases in each group. One group had re- ceived a face - to face follow - up at least once per month since 2010 and was enrolled in the delicacy management by using lifestyle in- tervention and medical treatment for 2 years ; whereas the other group was given a general management like the face - to face follow - up at least four times a year. The management effects and blood pressure control rates of the two groups were compared. Results： The blood pressure control rate in hypertension delicacy management group was 100% , and the average systolic blood pressure （SBP） was （ 128.51±11.42 ） mmhg and average diastolic pressure （DBP） was （ 74.89 ± 7.28 ） mmhg after two years＇ follow - ups ; whereas those in general management group were 86%, （ 131. 16 ± 12.64） mmhg and （76.20 ±9.79） mmhg, respectively. Differences of three indices between the two groups had the statistical significance. For the two groups, SBP and DBP were both improved compared those before the intervention, and the differences had the statistical significance. Conclusions： The delicacy management for the pa- tients with high blood pressure has the advantages of good effects and higher control rate, and is worth being popularized.