医院-社区综合管理模式对高血压患者服药依从性及血压控制效果的影响

目的通过建立医院．社区综合管理模式。提高患者在生活方式、血压监测、药物选择、服药依从性等方面的认知，并对其血压进行干预，提高血压控制效果及血压达标率，改善患者的生存质量；并将医院-社区双向管理模式向其他医院、社区推广。方法通过自行设计的血压监测的认知与依从性量表，首先了解东莞市石排镇1745名高血压患者的基本情况，随机抽取500名患者作为干预组，指导调整生活方式、血压监测、合理选药、加强服用药物的依从性；剩余高血压患者作为对照组，不做任何干预；定期每半月对两组血压情况、服药情况进行详细记录。随访1年，重新对血压进行评价，并对血压控制效果进行比较。结果经过医院-社区综合管理模式的干预，干预组患者在生活方式的调整、血压监测、药物选择、服药依从性等方面的认知明显提高，血压控制效果及血压达标率较前明显增高。结论通过医院-社区综合管理模式，能够提高患者在生活方式、血压监测、选择药物、服药依从性等方面的认知，明显提高患者血压控制效果及血压达标率，有效改善患者的生存质量；医院-社区综合管理模式在高血压病防治中值得向基层医院、社区推广应用。

Effect of hospital-community integrated managed system on drug compliance and blood pressure control for patients with hypertension

Objective To improve patients＇ understanding of life style, monitoring of blood pressure, drug choice and drug compliance by establishing hospital-community integrated management system, and to carry out an intervention on patients＇ blood pressure so as to improve the effect of blood pressure control and standard rate of blood pressure, and thus improve patients＇ life quality; to promote the hospital-community bidirectional management system to other hospitals and communities. Methods Basic conditions of 1745 patients with hypertension from Shipai Town of Dongguan City were primarily collected via self-designed questionnaires regarding the understanding and compliance of blood pressure monitoring. 500 patients were randomly allocated to an intervention group. Their life style, blood pressure monitoring and proper drug use were guided and their compliance of taking medicine was strengthened; the rest of patients were allocated to a control group without any intervention; conditions of blood pressure and drug use in the two groups were recorded in detail every half a month. The follow-up lasted for one year. Patients＇ blood pressure was re-evaluated and the effect of blood pressure control was compared. Results Thanks to the intervention of the hospital-community integrated management system, patients in the intervention group showed an improved understanding in terms of adjustment of life style, blood pressure monitoring, drug use and compliance of taking medicine. The effect of blood pressure control and target rate of blood pressure Significantly improved compared to the previous. Conclusion The hospital-community integrated management system helps improve patients＇ understanding of life style, blood pressure monitoring, drug use, and compliance of taking medicine, significantly improve the effect of blood control and target rate of blood pressure, and effectively enhance patients＇ life quality; the hospital-community integrated management system, in terms of prevention and control of hypertension, is worthy of promotion and application in primary hospitals and communities.