高血压患者全科团队式社区健康管理效果评估

目的 探讨对高血压患者实施全科团队式社区健康管理的效果.方法 选取本中心辖区内高血压患者219名作为研究对象,采取全科团队式健康管理进行社区综合干预,干预期为1年,评价干预效果.结果 在基线调查400名基础上筛选出232名药物治疗者进行健康管理,实际完成健康管理者219名,男女比例为1: 2.04,平均年龄(62.3±3.2)岁.健康管理前后患者对高血压相关知识知晓率、对全科医生管理的满意度、服药依从性、日常行为和血压变化情况比较,差异有统计学意义(P＜0.01).结论 全科团队式健康管理有助于提高社区居民对高血压病的知晓率、治疗率、控治率,达到控制血压、降低其他心脑血管疾病发病危险的目的 .

Evaluation of General Practitioner Team-based Community Health Management of Hypertension Patients

Objective To explore the general practitioner team-based community health management of hypertension patients and its effects.Methods An integrated community health intervention was performed by general practitioner team-based mode in 219 hypertension patients in our district,1 year.Intervention effect was evaluated.Results Based on baseline survey,232 patients receiving drug treatment were selected,and there were 219 valid questionnaires.Male to female ratio was 1: 2.04,averaging the age of 62.3 ± 3.20 year.There was significant difference in patients' awareness of hypertension-related knowledge,satisfaction with the team,medication compliance,daily behaviors and blood pressure changes between pre- and post-managements (P＜0.01).Conclusion General practitioner team-based health management helps increase hypertension awareness,the rates of treatment and control,to reach the purpose of controlling blood pressure and reduce the risk factors of other cardio-cerebrovascular diseases.