上海市高桥社区高血压新型管理模式的效果评估

The Appraisal of the Results in the New Management Mode of Hypertension in Gaoqiao Community of Shanghai

目的评价高血压的"团队管理群组"模式在高桥社区实施1年的效果,从而探索出符合高桥社区特点的、有效可行的高血压新型管理模式。方法按照以社区为基础的随机对照试验研究设计,以居委为单位将672名自愿参加该研究的高血压患者,随机地分为干预组(接受群组看病模式)和对照组(接受常规的高血压管理),干预、对照组各4个居委,干预组336名患者,对照组为336例。结果干预组的血压控制情况明显优于对照组,收缩压、舒张压及实验室指标的下降值均明显高于对照组;在生活行为方式上,干预组一贯优于对照组的三项指标(调节情绪、调理饮食、减少钠盐摄入)得到进一步强化,其向好的变化值明显高于对照组;高血压管理的总体自我效能评分比对照组明显提高;体育锻炼和医患交流两项指标也好于对照组。上述各项指标,差异均有统计学意义(P<0.05)。结论通过"团队管理群组"这样一个高血压管理模式在高桥社区实施一年后的效果评估显示该模式在高桥社区内是切实可行的、有效的。

Objective To appraise the results of ＂team management group＂mode of hypertension in Gaoqiao community after one year implementation,consequently explore a new,effective and feasible management pattern that conforms to characteristics of Gaoqiao community.Methods In the light of community,we adopt random control experiment to work over the design,and randomly divide 672 diabetic volunteers into two groups,one is intervention group accepted team management group pattern,the other is control group followed conventional hypertension management,the two groups made up of neighbourhood committees units each one has four neighbourhood committees within 336 patients in intervention group,and 336 ones in control group.Results Patients′ blood control in intervention group are obviously better than control group,their depression of systolic pressure,diastolic pressure and laboratory parameters are obviously higher than control group;On self-management behavior,the three targets of intervention group（adjust mood,regulate diet,reducing sodium intake）,which are always better than control group,have been further strengthened,and these good changes are clearly higher than control group;Total self-efficiency scores of hypertension management are highly better than control group;Two health functional indicators（physical training and communion with doctor）of intervention group are also significantly better than these in the control group.All the indicators above have statistically significant（P0.05）.Conclusion After one year implement,effect appraisal shows that this＂team management group＂pattern is practical and feasible in Gaoqiao community.