高血压社区管理新方法探索

Exploration of new methods for community management of hypertension

目的:探索"1+1+1"3级医疗机构联动模式用于高血压社区管理的可行性。方法:基于上海徐汇云医院和易问医平台建立"1+1+1"3级医疗机构联动模式,用于5家社区卫生服务中心的高血压患者的治疗、随访和管理。结果:2017年7—12月间,通过5家社区卫生服务中心,共入组了493例高血压患者,其中196例患者接受了长期随访,首诊率和复诊率分别为39.76%和1889.80%。在196例首诊患者中,在社区接受长期、稳定随访的有151例患者,他们的病情稳定;余下45例患者曾通过转诊系统转入徐汇区中心医院或中山医院治疗,病情得到良好的控制。结论:"1+1+1"3级医疗机构联动模式可使高血压社区管理更趋合理、科学,这种医疗机构联动模式本身也会得到广泛应用和普及。

Objective: To explore the feasibility of the alliance of 3 different levels of medical institutions in the whole process of hypertension management. Methods: The alliance of 3 different levels of medical institutions was established based on the Shanghai Xuhui Cloud Hospital and Yiwenyi platform, which was used for the treatment, follow-up and management of hypertensive patients from five community health service centers. Results: From July to December, 2017, 493 cases of hypertension patients from these 5 community health service centers were enrolled, in which 196 cases of patients underwent long-term follow-up and the initial diagnosis rate and referral rate were 39.76% and 1 889.80%, respectively. Among the 196 initial diagnosis patients, 151 patients who received long-term, stable follow-up in the community had stable conditions and the remaining 45 patients were transferred to the Central Hospital of Xuhui District or Zhongshan Hospital through referral system and their conditions were well controlled. Conclusion: The alliance of 3 different levels of medical institutions can make the management of hypertension in the community more reasonable and scientific and this alliance itself will also be widely used and popularized.