北京市怀柔区社区脑卒中高危人群干预效果

目的了解怀柔区脑卒中高危人群的干预效果。方法 2010年12月—2012年8月对怀柔区筛查出的318名45-79岁含有3项以上危险因素社区脑卒中高危人群,实施社区医生制定的个体化随访管理方案,2013年每3个月随访1次,填写社区脑卒中高危人群管理卡,分析干预效果。结果个体化随访管理后,平均血压值呈下降趋势,平均收缩压（SBP）和舒张压（DBP）分别下降3.2、2.4 mm Hg;高血压控制率从56.0%提高到74.5%,干预前后高血压控制率差异有统计学意义（χ2=24.139,P〈0.05）;医生进行健康教育率均明显提高,差异均有统计学意义（χ2=16.038,χ2=9.365,P〈0.05）;高危个体自我危险因素评价及采取的非药物治疗措施无变化。结论在社区中开展脑卒中高危人群个体化管理能够有效降低或延缓脑卒中的发病,在实际工作中应强化健康教育工作,促进高危个体建立良好行为,运用非药物治疗的措施降低或延缓脑卒中发病。

Intervention effect in high risk population of stroke in community of Huairou District in Beijing

[Objective]To understand the intervention effect in high risk population of stroke in Huairou District. [Methods]318people aged 45-79 years old,who have three or more risk factors of stroke by screening in community of Huairou District,received the individual follow-up management scheme which was designed by community doctor from December 2010 to August 2012. They were followed up once every 3 months,and filled in the community stroke high-risk people management card,to analyze the intervention effect.[Results]After individual follow-up management,the average blood pressure value showed a downtrend. The average systolic blood pressure（SBP） and diastolic blood pressure（DBP） decreased by 3. 2 mmHg and 2. 4 mmHg respectively. The control rate of hypertension increased from 56. 0% to 74. 5%,and there was significant difference in the control rate of hypertension between before and after intervention（χ2= 24. 139,P〈0. 05）. The rate of health education from doctors improved significantly,and the differences were statistically significant（χ2= 16. 038,χ2= 9. 365,P〈0. 05）. The differences in individual self-evaluation of risk factors and non-drug therapy measures were not statistically significant（χ2= 15. 799,χ2= 16. 038,χ2= 9. 365,P〈0. 05）.[Conclusion]In community,the individual management on high-risk population of stroke can effectively prevent or delay the onset of stroke. It is important to strengthen health education,promote high-risk individuals form good behavior,and apply non-drug therapy to prevent or delay the onset of stroke.