健康管理高血压患者血压控制及影响因素分析

目的 了解社区参加慢性病健康管理高血压患者常规随访情况、时期血压控制效果及影响因素，为完善社区健康管理提供参考依据。方法 采用多阶段分层随机抽样的方法抽取泸州市参加健康管理的高血压患者作为研究对象，采用现况调查与回顾性随访研究相结合的方法进行资料的收集。通过有序多分类logistic回归模型探讨时期血压控制效果的影响因素。结果 泸州市社区参加健康管理高血压患者随访达标率为52.1%，时期血压控制效果优良为55.1%。多因素分析结果显示，年龄为65~79岁（OR=2.822，95%CI:1.440~5.530）、退休人员（OR=1.350，95%CI:1.032~1.767）、参加健康管理超过2年（与＜2年相比，≥5年OR =1.434，95%CI:1.087~1.893；2~4年OR=1.459 ，95%CI:1.107~1.923）、自我报告规律服药（OR=1.860，95%CI:1.234~2.803）以及随访达标（OR=1.444，95%CI:1.157~1.803）患者时期血压控制效果更优良。结论 泸州市社区健康管理高血压患者常规随访达标率不高，时期血压控制效果也不太理想，亟需改善基层医疗卫生服务中心的医疗水平及服务质量，及早将患者纳入到规范化健康管理。

Analysis on the effect and influencing factors of blood pressure control in hypertensive patients with community health management

To understand the routine follow-up status, effect of blood pressure control and influencing factors of hypertension patients who participated in health management of chronic disease in the community health center, so as to provide reference for improving the quality of health management services. Methods Method of multistage was used to stratify sampling to extract hypertension patients of health management as the research object, and survey combined with a retrospective follow-up study of methods were used for data collection.Results The rate of compliance with follow-up of hypertension patients who participated in health management was 52.1%, excellent effect for blood pressure control during the period was 55.1%. The results of multi-factor analysis showed that the patients whose age ranges from 65 to 79(OR=2.822,95%CI:1.440-5.530), retirees(OR=1.350,95%CI:1.032-1.767),participants in health management more than 2 years(combine with<2 years, ≥5 years OR=1.434, 95%CI:1.087-1.893; 24 years OR=1.459,95%CI:1.107-1.923),has regular medication(OR=1.860, 95%CI:1.234-2.803) and has qualified follow-up times(OR=1.444,95%CI:1.157-1.803) have a better blood pressure control effect. Conclusion The rate of routine follow-up of hypertension patients who participated in health management is not high, period of blood pressure control effect is not ideal, we need to improve the basic medical level and service quality of health service center, early detect hypertension patients and included them into standardized health management.