高血压、糖尿病患者的社区管理现状研究

Community Management of Patients with Hypertension and/or Diabetes

目的评估高血压和糖尿病患者群体在社区卫生服务机构慢性病管理的现况。方法采用方便抽样法,对上海市某区2家社区卫生服务中心和三级医院的高血压、糖尿病门诊患者559人进行问卷调查,采用SPSS 16.0统计软件对数据进行统计分析。结果有74.7%的患者知晓社区卫生服务中心建档服务,32.3%的患者得到建档管理,其对社区慢性病管理的满意度评分为(3.57±0.65)分(5分制)。社区就诊患者接受建档管理的比例(36.0%)高于三级医院就诊患者(22.9%),差异有统计学意义(P<0.05)。高血压患者的血压控制率为44.1%,糖尿病患者的空腹血糖控制率为48.3%。研究对象中有47.2%的人超重或肥胖,34.7%的人服药依从性不佳。接受建档管理患者的血压、血糖控制率高于未接受管理者,但差异无统计学意义(P>0.05)。结论慢性病管理服务的覆盖面有待提高,需要重点关注体质量控制和提高服药依从性。

Objective To explore the community management of non-communicable chronic diseases-hypertension and diabetes. Methods Altogether 559 outpatients with hypertension and/or diabetes from two community health service（CHS） centers and one Grade 3 hospital were selected by convenient sampling and surveyed with questionnaire.SPSS 16.0 was used for statistical analyses. Results 74.7% patients were aware of the medical record service in CHS centers and 32.3% had been receiving these services.The average satisfaction score was（3.57±0.65）（total range from 1.0 to 5.0）.Patients receiving medical record service were 36.0% in CHS centers and 22.9% in the Grade 3 hospital,and the difference was significant（P0.05）.44.1% of the hypertensive patients maintained normal blood pressure,and 48.3% of the diabetic patients kept fasting plasma glucose under control.47.2% of the subjects were overweight or obese by BMI,and 34.7% had poor medication compliance.Patients receiving chronic disease management had higher blood pressure and/or blood sugar control rate than those not receiving,but the difference was not significant（P0.05）. Conclusion It is necessary to further expand the coverage of non-communicable chronic disease management and pay more attention to weight control and medication compliance promotion in CHS centers.