深圳市宝安区高血压糖尿病管治模式探讨

On of managed model for the hypertensions and diabetes in Baoan, Shenzhen

目的探讨高血压糖尿病管治模式。方法依据宝安区人民政府制订的《宝安区高血压糖尿病10年防治规划》,建立宝安区慢性病防治院、街道办事处卫生防保所和社区健康服务中心三级防治网,进行高血压糖尿病普查。成年的居民每年测1次血压和血糖,确诊的病例书写大病历,在社区实行终生管治,每月至少1次诊治病人或访视病人。结果较因症就诊多发现一半病例,有别于因症就诊只治不管和只治不进行综合防治的旧模式,有别于没有三级防治网,只在社区管治的国外模式。结论宝安区高血压糖尿病综合管治模式具有先进性与可操作性。

Objective To discuss a managed model for the patients with hypertension and diabetes.Method According to ' Ten year program for preventing and treating the patients with hypertension and diabetes in Baoan', three tiers of prevention and treatment network has been set up in which the upper tier is Baoan Chronic Disease Prevention and Therapy Hospital, the middle one is Health Care and Prevention Station in the street/township, and the lower is the Community Health Service Center. The network's performance included physical examination for every resident in the community once a year in order to find the new patient of hypertension and diabetes as well as to find the person with high risk in them. Treatment plan and community interference were established by the doctors in the network. They follow the patient once a month and every client got a prescription of remedies as well as health education.Result More patients were found and the effect was noted.Conclusion The model is valid and the process could be copied.