北京市大屯地区高血压患者分级管理一年成效分析

Results of grading management of hypertensive patients in Datun Community of Beijing for one year

目的评价大屯地区高血压患者分级管理效果。方法根据高血压水平和心血管危险因素对2009年10月1日至2010年10月1日间在大屯社区就诊的2137例高血压患者进行危险度分层,并采取三级(低危、中危、高危)分层管理,监测患者血压水平、血压控制(糖尿病患者血压<130/80mmHg,非糖尿病患者血压<140/90mmHg)率、非药物治疗比例及随访依从性等指标。结果入选高血压患者基线血压控制率为58.4%,其中,低危组、中危组、高危组分别为61.7%、57.2%、59.6%;随访1年时整体血压控制率为67.5%,其中,低危组、中危组、高危组分别为79.3%、55.4%、67.5%。与基线相比,仅低危组患者1年后血压控制率具有统计学差异(P<0.01)。低危组、中危组、高危组随访依从性达标率分别为72.5%、71.4%、82.6%。高危组随访达标率明显高于其他两组(P<0.01)。年龄、受教育程度和危险分层是影响随访达标率的因素。患者规律服药率超过90%,但非药物治疗率仅在50%左右。体育锻炼、限盐、控制体重对提高血压控制率有显著影响。结论社区高血压管理提高了血压控制率和随访依从性,中危组随访和血压控制情况较差。患者非药物治疗率仍较低,需要进一步改进健康教育和指导的方式和效果。

Objective To review the results of grading management of hypertensive patients in Datun Community of Beijing.Methods The degree of risk was graded in hypertension patients（n=2137）,visiting doctor in Datun Community from Oct.1,2009 to Oct.1,2010,based on their hypertension levels and cardiovascular risk factors,and managed according to three grades.The indexes including blood pressure（BP） level,control rate of BP,proportion of non-drug treatment and compliance rate of follow-up were observed.Results The control rate of baseline BP was 58.4% in selected hypertensive patients,and that was,respectively,61.7%,57.2% and 59.6% in low-risk group,average-risk group and high-risk group.After follow-up for one year,the control rate of BP was 67.5%,and that was,respectively,79.3%,55.4% and 67.5% in low-risk group,average-risk group and high-risk group.There was statistical difference in the control rate of BP only in low-risk group compared with baseline BP（P〈0.01） after one year.The compliance rate of follow-up was,respectively,72.5%,71.4% and 82.6% in low-risk group,average-risk group and high-risk group,and that was higher in high-risk group than that in other two groups（P〈0.01）.Age,education background and risk grading were factors influencing the compliance rate of follow-up.The proportion of patients taking drugs regularly was over 90%,but that of patients with non-drug treatment was only around 50%.Physical exercises,salt limitation and weight control had significant effects on the control rate of BP.Conclusion Community management of hypertension has improved the control rate of BP and follow-up compliance,but which was poor in average-risk group.The proportion of patients with non-drug treatment is still lower,and the methods and achievements should be improved in health education and guiding.