河北省沧州市农村居民高血压团队综合干预模式的实施与思考

Hebei Cangzhou rural residents hypertension team the implementation of the comprehensive intervention model and thinking

高血压为临床常见疾病,大多数病人需要终身进行抗高血压治疗。农村部分高血压病人对高血压病认识不足,不良生活方式难以改变、治疗依从性差等因素导致血压控制效果不理想。探索建立农村地区高效的高血压管理模式,以提高血压的控制效果,成为目前农村高血压管理亟待加强和改善的工作问题。以纳入基本公共卫生服务管理满一年的500例高血压病人为对象,实施为期一年的团队综合干预,详尽探讨团队综合干预管理模式的运行策略,并定期进行团队综合干预效果评估,期望能探索一条有效且高效的农村居民高血压管理新模式,为更好地管理农村地区高血压病人提供新的思路。

Hypertension for clinical common disease,most patients need a lifelong antihypertensive therapy. Rural part of patients with high blood pressure of hypertension awareness,lifestyle is hard to change,and poor treatment adherence factors causing blood pressure to control the effect is not ideal. Explore the establishment of rural area efficient hypertension management model,to improve the control effect of blood pressure,become the rural hypertension management work to strengthen and improve the problem. Will be incorporated in the basic public health service management for a full year of 500 cases of patients with high blood pressure as the object,comprehensive intervention,implement one-year team in detail comprehensive intervention team management mode of operation strategy,and the effect of comprehensive intervention on a regular basis team evaluation,expecting to explore an effective and efficient rural residents hypertension management mode,to better management of hypertension patients in rural areas to provide new ideas.