高血压患者不同社区随访管理模式干预效果评价

Evaluation on outcomes of different community follow-up management modes among community hypertension patients

目的了解浙江省杭州市余杭区不同社区随访管理模式对高血压患者管理效果的影响,为探寻新的管理模式提供理论依据。方法采用分层随机抽样方法在杭州市余杭区抽取的2 187例高血压患者进行问卷调查,应用SPSS 19.0统计软件分析不同社区随访管理模式对高血压患者高血压知识知晓率、服药依从性和行为改变的影响。结果余杭区高血压患者高血压知识知晓率、总体服药依从率和总体行为改变率分别为73.07%、54.78%和43.80%;单独式随访模式高血压患者高血压知识知晓率为70.00%,低于集体式随访模式的82.93%(χ2=253.621,P<0.001);单独式随访模式高血压患者总体行为改变率为45.98%,高于集体式随访模式的36.80%(χ2=9.370,P<0.05);单独式和集体式11种随访模式比较,医生上门+定期集中模式高血压患者高血压知识知晓率最高(99.67%),医生上门+病人到门诊模式高血压患者服药从率最高(88.24%),电话随访模式高血压患者行为改变率最高(67.15%)。结论集体式随访模式有利于高血压患者高血压知识知晓率的提高,而单独式随访模式更有利于患者行为的改变。

Objective To evaluate the effectiveness of different community follow-up management modes in community patients with hypertension in Yuhang district of Hangzhou city, and to provide a theoretical basis for developing new management model. Methods A total of 2 187 hypertension patients were selected from 20 villages/communities in Yuhang district of Hangzhou city with stratfied random sampling and investigated with a face-to-face questionnaire survey in 2012. SPSS 19. 0 was used in data analyses. Results The average age of the male patients （ 1 088,49.75% ） was 65.23 ± 10. 19 years and that of the female patients （ 1 099,50. 25% ） was 64. 90 ± 9. 99, without significant gender difference. The overall rates were 73.07 % ,54. 78 %, and 43.80 % for awareness of hypertension knowledge, adherence to medication, and behaviral change for hypertension control among the patients. The awarenss rate of hypertension knowledge in the patients with group follow-up（82. 93% ） was significantly higher than in the patients with individual followuP（X2 = 253. 621 ,P 〈0.001 ） ,whereas,the behaviral change rate of the patients with individual follow-up was significantly higher than that of patients with group follow-up （45.98% vs. 36. 80% ;χ2 = 9. 370,P 〈 0. 05）. There was no sig- nificant difference in medication adherence among the patients under different modes of follow-up （χ2 = 1.08, P 〉 0. 05 ）. The highest hypertension knowledge awareness rate（99.67% ） was reported in the patients with the doctor＇ s home visit plus regular group follow-up, the highest medication adherence rate（ 88.24% ） in the patients with the doctor＇s home visit plus visiting a doctor in the clinic, and the highest behaviral change rate （67.15 % ） in the patients with individual follow-up through telephone call. Conclusion The results of the study suggest that group follow-up is beneficial to increase awareness rate of hypertension knowledge and individual follow-up is beneficial to promote behaviral change among com- munity hypertension patients.