社区高血压系统管理近期效果评估报告

目的　寻找社区人群高血压综合防治的科学工作模式。　方法　在一个 3万人的社区人群中对 3 5岁以上人群开展高血压目标人群筛查 ,运用建立健康档案、开展健康生活行为教育、指导科学合理用药、随访督导服药的系统管理方法 ,对高血压病人开展综合防治。　结果　 18个月效果评估 ,14 0 4例高血压患者的良好生活行为形成率有了明显提高 ,吸烟率降低 3 5 .13 % ,饮酒率下降 4 4 .98% ,低盐膳食率提高了 73 .13 % ,规则服药治疗率由管理前 3 3 .1%提高到 90 .2 % ,有效降压率 90 .5 % ,治疗医药费成本平均每人每年减少了 5 8.12 %。　结论　在社区高血压患者实施防治结合 ,系统管理对促进高血压患者坚持长期服药 ,科学合理用药 ,有效平稳控制血压效果是显著的

Report About the Effect of System Management over Hypertensive Patients in Community

Objective To search for a scientific pattern of comprehensive prevention and treatment of primary hypertension in community population. Methods We firstly screened out the target people of hypertension in thirty thousand people whose ages are over thirty-five.Then cover the system management with health file building,health education. Rational treatment and regular follow-up were performed for prevention and treatment of hypertensive victims. Results Through evaluation on the 18 months, pepole had formed good life style and behavior. The rate of smoking and drinking decreased by 35.13% and 44.98%. Meanwhile, the rate of low-salt intaking increased by 73.13% .After management, the rate of regular medicine taking improved from 33.1% to 90.2% , and the medical costs per capita were reduced by 58.21%. Conclusions It is effective to systematically manage hypertensive patients in Community, which can urge victims to persist in long-term medicine taking, guide rational treatment scientifically and control blood pressure steadily.