深圳市社区劳务工实施高血压健康管理模式效果分析

Hypertension management for migrant workers in the community of Shenzhen city

对社区劳务工高血压患者实施“社区首诊、团队服务、首诊医师负责以及双向转诊”的健康管理模式，建立专案管理且超过6个月的患者为管理组，未进行专案管理但在本中心登记超过6个月的患者列为对照组。实施管理后，劳务工高血压患者新增筛查数量从2008年的32例增加到2010年的701例，新增管理数量从7例增加到348例。对464例患者进行问卷调查，其中管理组196例（回收186份），对照组268例（回收248份），显示管理组药物依从性好的占90．3％（168／186），明显高于对照组（26．6％，66／248，P=0．00）；血压控制满意率（87．1％，162／186）明显高于对照组（25．8％，64／248，P=0．00）；患者对社区卫生服务中心总体满意度为98．9％，明显高于对照组（88．7％，P=0．00）。提示，劳务工高血压患者管理模式的实施对提高高血压筛查、管理数量，改善患者就医行为及提高血压控制率起到了很好的作用。

The management model ＂primary care in community, team service, first contact physician responsibility and two-way referral＂ was implemented for migrant workers with hypertension in the community. The hypertensive patients under the management for over six months were assigned as management group; the patients who were registered but not under management for over six months served as the control group. The number of new cases detected in hypertension screening increased from 32 in 2008 to 701 cases in 2010; and number of hypertensive patients under management increased from 7 cases to 348 accordingly. A questionnaire survey was conducted in 464 hypertensive patients, including 196 cases in management group and 268 cases in control group with a response rate of 94. 9% （186/196） and 92. 5% （248/268） respectively. The results showed that drug compliance rate in management group （168/186, 90. 3% ） was significantly higher than that in the control group （26. 6% , 66/248, P = 0. 00）. The rate of blood pressure control in management group （87.1% , 162/186 ） was significantly higher than that in the control group （25.8% ,64/248, P=0. 00）. The overall satisfaction （98.9%） in management group was significantly higher than that in the control group （88.7%, P = 0.00 ）. The results indicate that implementation of the hypertension management in migrant workers improves the health seeking behavior and blood pressure control of patients.