以家庭为单位联合社区医疗网络对高血压病进行群体管理和个人管理相结合防治模式的效果评价

Effect evaluation of hypertension prevention and cure pattern combining group management and individual management by family-unit and community medical network

目的 评价以家庭为单位联合社区医疗网络对高血压病进行群体管理和个人管理相结合防治模式的管理效果.方法 以三水西南街道康华、布心、沙头、园林、文峰东等5个居委为主要试点,在知情同意的基础上筛选检出的原发性高血压个体300例,共300户家庭,按照综合医院负责指导培训和高血压重症管理;社区医院负责轻中症管理、建档、健康教育、随访、转诊;高血压群组和家庭成员互相协助、配合、督促的综合管理模式,登记、注册、建卡、建立高血压档案,对病患及其主要家庭成员家属进行健康教育,通过群组和家庭成员督促病者按时服药、就诊复查及改变吸烟、饮酒、过激、过劳等不良生活习惯,建立可行的个体化长期诊疗方案,随访观察1年后评价患者在干预前后的管理效果.结果 经过以家庭为单位的各级医疗网络联合干预后,患者的高血压知识掌握率明显提高,高血压知晓率从39.0％提高到99.0％、治疗率从65.0％提高到99.0％,控制率从22.7％提高到80.3％.吸烟、喝酒、高盐高脂饮食等高血压危险因素和血压值明显下降,新增心脑血管事件及其所致的致残率、死亡率均无明显增加,治疗费用从每周（27.17±6.44）元降至每周（11.48±2.85）元.结论 建立以综合医院为指导,社区医院负责轻中症治疗、随访、宣教,高血压群组和家庭成员互相协助、配合、督促,群体管理和个人自我管理相结合的综合医院-社区医院-高血压家庭群组/家庭户-个人的管理模式能对高血压病进行有效管理.

Objective To evaluate the effect of hypertension prevention and cure pattern which combines group management and individual management by family-unit and community medical network.Methods 300 patients with essential hypertension from 300 families of residents committees such as Kanghua,Buxin,Shatou,Yuanlin,Wenfengdong,were trained and managed under general hospitals by informed consent.The community hospitals took the responsibility for management,establishing files,health education,followup and referral of mild and moderate cases.Patients took medicine,had subsequent visits,and changed bad habits such as smoking,drinking,superexcitation and overwork with the help of their families.Individual long-term diagnosis and treatment schemes were implemented.Evaluated the interference effect after 1 year.Results The rates of awareness,treatment and control increased significantly (39.0％ vs.99.0％,65.0％ vs.99.0％,22.7％ vs.80.3％).The risk factors of hypertension such as smoking,drinking,high-salt and highfat diet,and blood pressure presented the downward trend after comprehensive interference.The new onset of cardiovascular and cerebrovascular events and their disability rate and mortality didn' t increase obviously.The cost of treatment decreased [(27.17 ± 6.44)yuan per week vs.(11.48 ± 2.85)yuan per week].Conclusions The general hospital-community hospital-group-individual management mode which is guided by general hospital,and is responsible for treatment by community hospital can manage hypertension more effectively.Under this mode,follow-up and education of mild and moderate cases are helped with families with integrity of group management and individual management.