基层社区卫生服务中心的高血压家庭医生管理模式评估

The Evaluation of Family Doctor Care for Hypertension Management in Primary Community Health Care Center

目的通过基层社区卫生服务中心家庭医生服务模式开展前后高血压患者管理情况的对比调查,评估家庭医生服务模式对高血压管理的效果。方法根据宁波市家庭医生服务相关政策和已有的临床资源,自2014年开展高血压患者的家庭医生服务管理干预。采用Mac OS X 10.12平台的R 3.2.2(R project)统计学软件,对2013-2015年社区卫生服务中心高血压患者管理数据进行回顾性统计和作图分析,比较家庭医生服务模式开展前后的各项临床指标,评估高血压患者的家庭医生服务效果。结果 2013-2015年社区卫生服务中心每月管理患者中位数(四分位数)为5 598(5 472,5626)人,5789(5 621,5 919)人和6 359(6 186,6 458)人;开展家庭医生服务后的2014年和2015年每月管理人数的中位数相较于服务前2013年每月管理人数呈现显著上升(P<0.05);3级高血压患者管理和随访人数则在开展服务后呈现下降(P<0.05)。2014年和2015年患者收缩压和舒张压水平相较于2013年呈现持续下降(P<0.05),2014年总胆固醇、甘油三酯和低密度脂蛋白水平较2013年有显著下降(P<0.05)。结论家庭医生服务能够有效控制社区高血压患者的血压和血脂水平,个体化治疗和综合性的健康教育活动能够有效提升高血压患者长期管理效果和依从性,有助于改善患者的长期预后。

Objective To compare the management status of hypertension population before and after the applica- tion of Family Doctor Care in primary community health care center and evaluate the management of Family Doctor Care. Methods According to the policies of family doctor care in Ningbo and clinical resource, the fami- ly doctor care of hypertension has been applied since 2014. Based on the R 3.2.2 （ R project） Statistic Soft- ware on Mac OS X 10. 12, the management data of hypertension population were analyzed with retrospective de- scription and visualization in primary community health care center, and the clinical indicators were compared before and after the application of Family Doctor Care from 2013 to 2015, to evaluate the service effect of family doctor care. Results The median （ interquartile range） per month of the hypertension population was 5 598 （5 472, 5 626）, 5 789 （5 621, 5 919） and 6 359 （6 186, 6 458） from 2013 to 2015, respectively; the median number of monthly patients after the Family Doctor Care in 2014 and 2015, was significantly higher （P 〈 0.05 ） than that of 2013 ; and the median management and follow - up numbers of hypertension stage 3 patients were significantly decreased （ P 〈 0.05 ） in 2014 after the Family Doctor Care. The systolic and diastolic blood pressure in 2014 and 2015 were significant decreased （P 〈 0. 05 ） ; and the level of total cholesterol, triglyceride and low- density lipoprotein in 2014 decreased significantly compared with that of 2013 （P 〈 0.05 ）. Conclu- sion Family Doctor Care Services can effectively control the blood pressure and lipid levels in community hyper- tension patients. Individualized treatment and comprehensive health education activities can improve the effect of long - term management and compliance, to get better the long - term clinical outcomes.