高血压病社区医院之间危险度分级管理模式的效果

The mode of community-hospital criticality of dividing-level management on high blood pressure's effect

目的了解社区医院之间的高血压分级管理模式实施半年后对高血压患者的管理现状及效果。方法采用《中国高血压防治指南》(2005年修订版)的诊断标准对正在管理的234例高血压患者的管理现状进行分析。结果①高血压患者管理率达到89.7%;②极高危组有63例患者降到高危组,降级率为39.1%;高危组有26例患者降到中危组,降级率为50.9%;中危组有8例患者降到低危组,降级率为34.8%;低危组有11例患者血压控制在正常范围,占低危组患者的42.3%。在管理级别上,强化管理组有62例降到一般管理组,降级率为59.6%,中度管理组有8例降到一般管理组,降级率为47.1%。经统计学分析,管理前后各项指标差异有统计学意义(P<0.05)。结论①社区医院之间的高血压分级管理是社区控制高血压的有效干预措施。②通过医患交流、健康教育等措施进一步加强患者自我管理,提高患者依从性。③进一步建立与完善数字化网络管理体系,定期评估健康状态与危险分层、指导治疗,形成系统的疾病管理与评价体系。

Objective To investigate the management situation and influence of the mode of dividing-level management on high blood pressure to hypertensive patients half a year later in community-hospital. Methods According to Chinese Hypertension Guide, the management situations of 234 hypertensive patients were analyzed. Results ①The managing percentage of hypertensive patients was 89.7%. ② The results showed that 63 patients of very high risk group（39.1%） descended to high risk group, 26 patients of high risk group（50.9%） came down to medium risk group,8 patients of medium risk group（34.8%） fell down to low risk group, 11 patients of low risk group （42.3 %） controlled blood pressure in normal standard. About management grade, the results showed that 62 patients of comprehensive intervention（59.6%） was put down to mamagement group, 8 patients of medium management group （47.1%） came down to mamagement group. According to statistic analysis, there was significant difference among before and after high blood pressure patients management. Conclusion ①Community-hospital of dividing-level management on high blood pressure is effective interfering measurement for community to control high blood pressure. ②Through doctor-patient communication, health education, patient self-management and compliance can be improved. ③Digital network management system can further be established, health status and risk stratification gets regular evaluation,guiding treatment to form systematic disease management and evaluation system.