医院-社区一体化模式对社区老年高血压分级管理的效果

目的：评价医院-社区一体化分级管理模式对社区老年高血压患者的管理效果，探索社区老年高血压有效管理模式。方法：2013年6月采取随机抽样的方法从长沙市某社区卫生服务中心随机抽取218名原发性老年高血压患者(男121名，女97名)，根据心血管风险分级，将研究对象随机分为3个管理组(低危、中危、高危/很高危)，对各组分别展开6个月医院-社区一体化分级管理。采用《HILL-BONE高血压依从性评估表》及自行设计的《血压监测登记表》，评估老年高血压患者的血压控制情况和就医依从性。结果：干预6个月后，血压控制率由22.9%提高至88.1%(P<0.01)；与基线水平比较，低危组、中危组、高危组/很高危组收缩压水平分别下降17，20和23mmHg(P<0.01)，舒张压水平分别下降6，5和7mmHg (P<0.01)；HILL-BONE高血压依从性由54.5%提高至87.4%(P<0.01)。结论：医院-社区一体化分级管理模式能提高社区老年高血压患者血压控制率、治疗依从性及合理用药率，值得在社区老年高血压病防治中推广。

Effect of the integration pattern of hospital-community on the grade-based management for hypertension in elders

Objective: To investigate the effect of the integration pattern of hospital-community on the grade-based management for hypertension in elders. Methods: We randomly chosen 218 (male, n=121; female, n=97) primary senile hypertension patients from a Community Health Service Center of District in Changsha City, from June, 2013 to December, 2013. Based on the risky factors, the subjects were divided into three groups and every group received grade-based management on blood pressure with a integration pattern of hospital-community for six months. According to the HILL-BONE high blood pressure compliance scale and the self- designed blood pressure monitoring form, we assessed the effect of compliance and blood pressure control on senile hypertension patient. Results: Hypertension treatment rate for the elders ranged from 22.9% to 88.1% (P<0.01). The levels of blood pressure of the subjects were significantly decreased compared with baseline. The level of diastolic blood pressure in the low, average, high and very high-risk group was decreased by 17, 20 and 23 mmHg, respectively (P<0.01). The level of systolic blood in the low, average, high and very high-risk group was decreased by 6, 5 and 7 mmHg, respectively (P<0.01). The compliance rate of HILL-BONE hypertension rose from 54.5% to 87.4% (P<0.01). Conclusion: The integration pattern of hospital-community with the grade-based management for hypertension significantly improved the senile hypertension control rate and compliance of drug treatment. The rational for drug usage rate rose obviously. The integration pattern of hospital-community with the grade-based management for elders deserves to spread.