北京市某社区高血压患者及其高危人群的社区干预效果分析

 目的 评价社区开展高血压患者和高血压高危人群高血压规范化管理的效果.方法 随机抽取北京市丰台区南苑社区参加规范化管理的高血压患者和高血压高危人群作为研究对象.采用高血压分级管理,通过健康教育和健康促进,优化生活方式,控制危险因素,指导规律性用药等措施进行社区人群综合性干预,追踪随访观测4年,对干预效果进行评价.结果 与基线相比社区内高血压患者血压控制情况明显得到改善,4年平均收缩压分别为(140.48±1.11),(132.32±0.87),(130.75±1.65),(126.98±1.32) mmHg(P﹤0.01);平均舒张压分别为(94.68±5.81),(80.80±0.72),(84.01±4.97),(79.91±0.82) mmHg(P﹤0.05).按医嘱服药情况明显得到改善(P﹤0.05),高血压高危分层结构比例明显改善(P﹤0.05),高血压患者高盐和高脂饮食的比例明显降低,患者中经常食用豆制品和注意保持心理平衡的所占比例明显增加(P﹤0.05).高危人群上述指标均没有明显改变(P﹥0.05).结论 社区开展高血压规范化管理可以改善高血压患者的高危分层结构比例,促进患者有规律服药,有效控制血压水平.

Effect of intervention on hypertensive patients and high-risk group of hypertension at Nanyuan Community in Beijing

Objective To evaluate the effect of community management on hypertensive patients and high - risk group of hypertension. Methods The hypertensive patients and high - risk group of hypertension were randomly selected from Nanyuan communities of Fengtai District in Beijing as subjects of hypertension standardized management, and the basal information was obtained through questionnaires and physical examination; then the hypertensive patients were stratified by risk factors. The hypertensive patients were managed at different levels, and comprehensive intervention was carried out through health education and health promotion, optimization of life style, control of risk factors and guiding regular medication. They were followed up for 4 years （ 2006 ± 2009 ） ; their data were analyzed using SPSS statistical analysis software to evaluate the effect of the intervention. Results The blood pressure was signifi- cantly improved, compared with basal information. Four - year average systolic blood pressures were （ 140.48 ± 1.11, 132.32 ± 0.87, 130.75 ± 1.65, and 126.98± 1. 32 mmHg, P 〈 0.01 ） ; the average diastolic blood pressure were （94.68 ± 5.81, 80.80 ± 0.72, 84.01 ±4.97, and 79.91± 0.82 mmHg, P 〈 0.05 ）. The medication under the guidance of the doctor was significantly improved （ P 〈 0.05 ）. The proportion of high fat and high salt diet population with hypertension was significantly reduced （ P 〈 0.05 ） , and the proportion of people who regularly consume soy products and pay attention to maintaining psychological balance significantly increased. Conclusions The standardized management of hypertensive patients and high risk population in Nanyuan communities changes the proportion of risk stratification, promotes the regular medication and effectively controls the blood pressure.