高血压社区疾病管理计划的应用研究

The Applied Research of Disease Management Programmed for Hypertension in Community.

目的探讨适合不同地区和人群的可持续发展的高血压社区疾病管理模式。方法①分别选择城市、农村和城镇三个社区中15岁以上常驻(居住半年以上)人群为高血压疾病管理对象。②根据《中国高血压防治指南》制定"规模化、规范化和信息化"为核心的高血压社区疾病管理计划。③围绕高血压的防治目标建立信息化管理网络。④每个实施阶段都设置了相应培训内容和考核评估标准。结果①专业人员的高血压防治知识水平有大幅度提高。社区人群管理能力及自身发展能力明显提高。社区相关政策及环境有显著变化。②迅速提高高血压"三率"、人群平均血压水平有所下降、不良生活方式及行为有所改善、急性事件的发生较周边社区减少。③群众对社区卫生服务的信任、满意度增加。结论高血压社区疾病管理计划不仅在城市社区可以有效实施,在农村实施同样也可以达到预期的效果。

Objective The discussion suits different local and crowd＇ s sustainable development hypertension community disease manages the pattern. Methods （1） separately chooses the city, the countryside and in the cities tKree commtmities above 15 years old resident （lives above for half year） the crowd to manage the object for the hypertension disease. （2） ＂Prevents and controls Guide according to the Chinese Hypertension＂ to formulate ＂the scale, the standardization and the information＂ manages the plan for the core hypertension commtmity disease. （3） Revolves the hypertension the preventing and controlling goal establishment information management network. （4） Each implementation stage has all established the corresponding training content and the inspection appraisal stan- dard. Results （1） Specialist＇s hypertension prevents and controls the state-of-art to have the large scale enhancement. Community crowd management ability and own development ability distinct enhancemem. Commtmity correlation policy and environment change. （2） Rapidly enhances the hypertension ＂three rate＂, the crowd average blood pressure level has the drop, not the good life style and the behavior has the improvement, the acute event occurrence comparatively peripheral commtmity reduces. （3） Populace to community health service trust, degree of satisfaction increase. Conclusions The hypertension community disease manages the plan not only to be allowed effectively to implement in the city community, similarly also may achieve the anticipated effect in the countryside implementation.