城市社区人群高血压管理模式与干预方案的探索

Exploration on management model and intervention project of hypertension in urban community

目的探索城市社区高血压管理模式与干预方案的可行性。方法抽取上海市南市区半淞园街道内的１０个居委会的３５２３名高血压患者作为管理干预组，同时抽取另１０个居委会的３４１７名高血压患者作为对照组。管理采用临床门诊、社区设点与上门随访相结合的方式，对被管理对象按照其血压水平与靶器官受累程度进行分级管理和干预。结果管理后１年一、二级管理对象的管理率分别达到８３．６６％和８１．９５％，高血压控制率达到６２．１９％，管理干预组卒中的发病数与死亡数也少于对照组。结论社区高血压人群的管理和干预对高血压控制和降低并发症具有重要作用。

Objective To explore the feasibility of the management model and intervention project of hypertension in urban community. Method 3523 people who had hypertension in ten resident committees were selected as case and 3417 in another ten resident committees were matched as control. Management included clinic,set post in community and home visits.Cases with different degree hypertension were intervened by different method and intensity. Results The management rate of cases in 1st and 2nd degree were 83.66 and 81.95 percent. The rate of hypertension controlled was 62.19 percent. New cases of stroke and death in intervention group was less than that in control group. Conclusion Management and intervention of hypertensive patients are important for controlling hypertension and reducing complications.