三级危险分群管理在社区老年高血压防控中的应用

Three-tier Risk Grouping Management in Hypertension Prevention and Management in the Elderly in Community

目的将三级危险分群管理应用于高血压疾病的社区管理,以探讨危险分群管理对高血压的防控作用。方法将社区老年人分为全人群、高危人群和高血压患者三级人群,对不同人群实施相应的高血压防控措施,分别在项目实施前(2003年)、中(2006年)、后期(2010年)进行调查。结果自2003年至2010年,社区老年人的高血压患病率从53.0%增高至68.8%,各阶段差异均有统计学意义(P<0.01);实施三级危险分群管理中期和后期,社区老年人的高血压知晓率和治疗率均高于管理前期(P<0.01);管理中期高血压控制率高于管理前期(P<0.05),但管理后期高血压控制率反而略有下降。结论面对老年人群高血压流行的现状,高血压防控工作仍需进一步加强;而三级危险分群管理能将家庭、社区和医院有机结合在一起,提高高血压防控工作的效果。

Objective To explore the efficacy of stratified risk management in hypertension prevention and management by using 3-tier risk grouping approach in community.MethodsThe community residents were clustered and identified as ＂the whole population＂,＂the high-vulnerable population＂ and ＂the patients with hypertension＂.Each group was treated with either hypertension prevention or control approaches.Investigations were conducted before（2003）,during（2006） and after（2010） the interventions.ResultsDuring the period of 2003 and 2010,the prevalence of hypertension of the elderly in community increased from 53.0% to 68.8%,with statistically significant differences in various stages（P0.01）.At the middle and late stages of the project,3-tier risk grouping management significantly reduced the hypertension prevalence,enhanced patients＇ disease awareness and improved cure rate compared with those before the project（P0.01）.Specifically,the mid-stage hypertension control rate was significantly increased compared with prior project（P0.05）;the late-stage hypertension control rate was slightly decreased than the mid-stage.ConclusionConsidering the high prevalence of hypertension in the elderly population,the measures of prevention and control hypertension should be further strengthened;The 3-tier risk grouping approach can combine family,community and hospital together to effectively prevent and manage high blood pressure among communities.