家庭医生签约式服务模式对社区高血压患者管理效果

Effect of family doctor contracted service model on hypertension management in community patients

目的评价家庭医生签约式服务模式对社区原发性高血压患者管理效果。方法选取2015年1月~12月于北京市海淀区北下关社区卫生服务中心实施家庭医生签约式服务模式的原发性高血压患者891例,其中男性518例,女性373例。建立社区患者电子健康档案,根据患者血压控制情况和自身情况,实施个体化管理12个月,对比管理前后血压、体质指数、空腹血糖、血脂及血压达标率,生活方式改变情况。结果与管理前对比,入选患者实施个体化管理后血压、体质指数、空腹血糖、三酰甘油、总胆固醇、低密度脂蛋白胆固醇均显著下降,内生肌酐清除率、尿微量白蛋白均改善,差异有统计学意义(P均<0.05)。患者实施个体化管理后较管理前血压达标率显著升高,94.1%vs.27.5%,差异有统计学意义(P<0.01)。与管理前比较,入选患者个体化管理后吸烟、饮酒比例下降,运动情况、摄盐情况及治疗依从性均明显改善,差异有统计学意义(P均<0.01)。结论家庭医生签约式服务模式可有效控制社区原发性高血压患者血压和危险因素,明显改善生活方式。

Objective To review the management effect of family doctor contracted service model in community patients with essential hypertension （EH）. Methods EH patients （n=891, male 518 and female 373）, who were received family doctor contracted service model, were chosen from the Beixiaguan Community Health Center in Beijing Haidian Distriction from Jan. 2015 to Dec. 2015. The community electronic health records were established, and all patients were given individualized management according to management of blood pressure （BP） and their own situations for 12 m. The changes of BP, body mass index （BMI）, fasting blood glucose （FBG）, blood fat, BP compliance rate and life style were compared before and after management. Results The levels of BP, BMI, FBG, triglyceride （TG）, total cholesterol （TC） and low-density lipoprotein-cholesterol （LDL-C） decreased significantly, and endogenous creatinine clearance rate （CCr） and urinary micro albuminuria （U-mAlb） were improved significantly after management （all P〈0.05）. The BP compliance rate was significantly increased after management compared with that before management （94.1% vs. 27.5%, P〈0.01）. The percentage of smoking and drinking patients decreased, and situations of exercises, salt-taking and treatment compliance were significantly improved after individualized management （all P〈0.01）. Conclusion The family doctor contracted service modelcan effectively control BP and risk factors, and improve significantly life style in community patients with EH.