南通市学田社区老年高血压细节干预效果评价

Effective Evaluation of Community Intervention for Aging Patients with Hypertension by Disease Details Management in Nantong Xuetian Community

目的:观察细节干预在社区老年高血压治疗中的有效性和实用性。方法:将南通学田社区83例老年高血压患者分为对照组(29名)和细节管理组(56名)。细节管理组:设立社区健康管理专员专岗,增进社区医生与患者的沟通,提高患者服药依从性,对患者进行生活方式指导,并为社区医生定期收集血压等相关信息并反馈;开发和应用社区管理信息平台和患者管理工具。日常管理组:采用常规的管理模式,比较6个月治疗前后的血压控制情况。结果:两组间干预前后的血压均值间差别均有显著性意义(P<0.05)。结论:细节干预是进行老年高血压患者二级预防的有效社区干预模式,有利于整个人群高血压的预防和控制。

Objective：To observe the efficacy and practicability of Disease Details Management regimen intervention in patients with hypertension. Methods：Totally 83 subjects were divided into intervention group and control group. Intervention group received Disease details management regiment intervention on the basement of methods in control group. After 6 months, The intervention programs for the intervention group included disease management by special care managers who enhance communication between physicians and patients,promote medication compliance and give guidance of health lifestyle for patients; collect the related information on blood pressure,etc. As well as feedback from patients for community practitioners; and community-based management information platforms and patient management tool were also developed and applied. Before and after treatment blood pressure were detected so as to compare the Intervention group andthe control group. Results：The differences were all significant （P〈0.05） between the two groups before and after intervention in blood pressure. Conclusion：Disease details management program for aging people with hypertension is effective to improve the degrees of awareness of related knowledge and control of the blood pressure.