医联体对社区原发性高血压患者的分级诊疗和规范化管理的作用

Effect of regional medical consortium on standardized management of stratified diagnosis and treatment in patients with hypertension in community

目的探讨医联体对社区原发性高血压(高血压)患者的分级诊疗和规范化管理的作用。方法随机选取2016年1月至2017年9月35～75岁北京东城区社区卫生服务中心高血压患者1 000例;对其建立电子健康管理档案并随访观察半年;给予相应的规范化管理。观察对比管理前后每组高血压知晓率、服药率、控制率、血压达标率情况;血糖、血脂、吸烟、体质量指数等心血管危险因素的控制情况;以及不良生活方式的改变、运动康复情况。结果通过医院与社区联合规范化管理高血压患者,其高血压知晓率(67.3%vs. 89.6%)、治疗率(79.8%vs. 90.6%)、控制率(69.4%vs. 81.2%),达标率(58.6%vs. 75.1%)均明显提高,与管理前比较,差异均有统计意义(P<0.001)。收缩压[(152.42±13.531)mmHg vs.(129.47±12.38)mmHg;1 mmHg=0.133 kPa]、舒张压[(98.32±12.121)mmHg vs.(77.47±14.38)mmHg]、血糖[(8.89±1.76)mmol/L vs.(6.48±1.81)mmol/L]、总胆固醇[(6.42±0.52)mmol/L vs.(4.58±0.62)mmol/L]、低密度脂蛋白胆固醇[(4.28±0.39)mmol/L vs.(3.06±1.24)mmol/L]等较管理前控制好,差异有统计学意义(均为P<0.05)。同时患者在按时服药(70.1%vs. 86.4%)、低盐低脂饮食(59.1%vs. 75.3%)及合理运动(68.6%vs. 84.1%)生活方式方面优于管理前,差异有统计学意义(均为P<0.05)。管理后新诊断的高血压并发冠状动脉粥样硬化性心脏病(冠心病)(15.2%vs. 26.9%)、并发糖尿病(17.6%vs. 21.5%)、并发颈动脉狭窄(0.9%vs. 1.6%)患者比例较管理前增多,差异有统计学意义(均为P<0.05)。结论通过医联体分级诊疗对高血压患者规范化管理,能够提高患者高血压的知晓率、达标率、控制率、服药依从性,并有效改善患者的各项指标;同时积极控制心血管危险因素,能早期及时诊治高血压并发冠心病、并发糖尿病、并发心力衰竭、并发颈动脉狭窄等患者。

Objectives To explore a standardized management of the stratified diagnosis and treatment for community hypertension patients ： the effect of regional medical consortium. Methods We randomly recruited 1 000 aged 35-75 hypertension patients in Community Healtheare Center In Beijing Dongeheng District from January 2016 to December 2017, and established the electronic health management files. During six months follow-up, a standardized management with the diagnosis and treatment had been executed. The following items had been observed before and after the standardized management ： hypertension awareness rate, cure rate, maintenance of blood pressure and goal of blood pressure. Also, some cardiovascular risk factors like blood glucose, blood lipids, smoking, body mass index （BMI） , life style changing, sport and rehabilitation, and so on were observed. Results Through the standardized management by regional medicl consortium for community hypertension patients, hypertension awareness rate （67.3% vs. 89.6% ） , cure rate （79.8% vs. 90.6% ） , maintenance of blood pressure （69.4% vs. 81.2% ） and goal of blood pressure control （58.6% vs. 75.1%） had been improved significantly （P〈0.001） ; systolic blood pressure [ （152.42±13.531） mmHg vs. （ 129.47± 12.38） mmHg; 1 mmHg=0.133 kPa], diastolic blood pressure [ （98.32±12.121） mmHg vs. （77.47± 14.38） mmHg ], blood glucose [ （8.89± 1.76） mmol/L vs. （6.48± 1.81 ） mmol/L ], total cholesterol [ （6.42±0.52） mmol/L vs. （4.58 ±0.62） mmol/L ] and low density lipoprotein cholesterol [ （4.28 ±0.39） mmol/L vs. （ 3.06 ±1.24） mmol/L ] had also been improved significantly （P〈0.05）. In the meantime, the patients got better in their medicine compliance （70.1% vs. 86.4% ） , lifestyle changingwhich including low diet salt （59.1% vs. 75.3% ） and moderate sport （68.6% vs. 84.1% ） （P〈0.05）. Number of newly diagnosed hypertension patients complicated with coronary heart disease （15.2% vs. 26.9%） , diabetes （17.6% vs. 21.5%） and carotid stenosis （0.9% vs. 1.6%） increased compared with those before management （P〈0.05）. Conclusions For community hypertension patients, a stratified diagnosis and treatment through the regional medical consortium, and a standardized management will improve their hypertension awareness rate, medicine compliance, goal of blood pressure control and maintenance of blood pressure, also for some laboratory blood tests. In the meantime, some cardiovascular risks will be reduced. Also, early and timely diagnostic and therapeutic processes can be executed by heart expertise for hypertension patients with coronary disease, diabetes, heart failure and with carotid artery stenosis.