上海市普陀区高血压社区规范管理的模式和效果探讨

目的在社区进行高血压规范管理,观察高血压治疗率和控制率,了解血压水平和心血管危险分层的变化。方法 2009-04-2010-04在上海市普陀区4个社区2048人中检查出高血压患者977例,按照心血管危险因素分层实行分级管理1年,设立健康管理专员进行管理,随访包括血压测量、健康教育和治疗方案调整。结果高血压患者977例一年的规范管理率88.9%;管理前后高血压的治疗率从66.7%(652/977)提高到73.6%(655/890),高血压控制率从41.3%(403/977)提高到61.8%(550/890),分别增加了6.9%和20.5%,差异有统计学意义(P<0.01);与基线调查时相比,1级高血压患者减少22.8%,2级高血压患者减少4.3%,3级高血压患者减少0.3%;在重新评估的心血管危险因素分层状况中,低危患者人数增加0.2%,中危患者人数减少0.6%,高危患者人数增加1.2%,很高危患者人数减少0.8%;吸烟者、超重者、缺少运动者分别减少0.8%、0.4%、2.0%,血脂异常者减少4.9%(P<0.05);总胆固醇、三酰甘油和低密度脂蛋白总胆固醇分别降低0.20、0.30和0.14mmol/L(P<0.01)。结论健康管理专员模式在社区是能被患者接受的,规范管理后,使社区高血压患者的血压水平下降,高血压控制率得到了明显的提高。

Study on the mode of community-based standard management and its effect on hypertension in Putuo district,Shanghai

Objective In four communities of Putuo district, Shanghai,we aimed to implement the standard management on hypertension,observe hypertension treatment and control rate,and investigate the variations in blood pressure and cardiovascular risk profiles. Methods A total of 977hypertensive patients from these four communities,and performed the graded administration upon these patients according to the cardiovascular risk profiles, 2009-04-2010-04. Also we recorded their blood pressure readings,health education and treatment adjustment. Results The management rate in one year was 88.9%in 977 hypertensive patients. Hypertension treatment rate from 66.7% (652/977)to 73.6% (650/890),P<0.01]and control ratefrom 41.3% (403/977)to 61.8% (550/890),P<0.01]were significantly increased after the administration. Compared with the baseline,the num- ber of hypertensive patients were reduced by 22.8%,4.3%and 0.3%in the first,second and third graded level of hypertension,respectively. After stratification upon cardiovascular risk profiles,the number of hypertensive patients was increased by 0.2%in low-risk patients,reduced by 0.6%in middle-risk patients,increased by 1.2%in high-risk patients and reduced by 0.8%in very-high-risk patients. In addition,there was a reduced trend towardssmoking(by 0.8%),overweight(by 0.4%),insufficient exercise(by 2.0%)and dyslipidemias(by 4.9%)(P< 0.05),and levels of plasma total cholesterol,triglyceride and low-density lipoprotein cholesterol were significantly reduced by 0.20,0.30and 0.14mmol/L,respectively(P<0.01). Conclusion Most hypertensive patients can benefit from the community-based health administration,after which their blood pressure levels are reduced,and the hypertension control rate has been greatly improved.