高血压社区综合干预信息化管理模式的探讨

目的：摸索一套适宜农村社区＂规范化、规模化和信息化＂的高血压社区综合干预管理模式。方法：按照《浙江省高血压社区综合干预信息化管理》（简称《规范》）实施方案,采用省心脑血管病防治中心专门指定的高血压防治管理系统（gxy.u1000.net）,对辖区内≥18岁的户籍居民进行健康基线调查,对社区责任医生培训,按结果将调查对象分为一般人群、高危人群和高血压患者,按血压水平和危险因素分布,实施社区人群的高血压分类管理和综合干预。结果：该社区居民高血压治疗率、控制率和知晓率有明显上升,高危人群各类危险因素明显下降。结论：在农村社区实施高血压社区综合干预信息化管理是切实可行的。

Information management model of comprehensive intervention of high blood pressure in communities

Objective To explore an information management model of comprehensive intervention of high blood pressure in communities.Methods Based on the scheme of Zhejiang Information Management Model of Comprehensive Intervention of High Blood Pressure in Communities,management system of high blood pressure prevention（gxy.u1000.net）,which was designated by Provincial Prevention Center of Cardiovascular Diseases,was adopted.Baseline investigation was made in permanent residents above 18 years old.Community doctors who had been trained divided the objects into common population,high risk population and high blood pressure patients according to the results of the investigation,then category management and comprehensive intervention was conducted based on blood pressure levels and risk factors distribution.Results Curative rate,control rate and knowledge rate of high blood residents increased significantly,while risk factors of high risk population decreased obviously.Conclusion It is feasible to carry out information management of comprehensive intervention of high blood pressure in rural communities.