社区强化管理达标模式在高血压未控制患者中的应用效果分析

Effectiveness of intensive hypertension management model for patients with uncontrolled blood pressure in community

目的探讨对慢病分级诊疗中高血压未控制患者实施社区强化管理达标模式的效果。方法纳入上海市嘉定区社区卫生服务中心门诊2015年5月至2017年12月经2种或2种以上降压药治疗血压未控制患者307例,采用社区强化管理达标模式,由全科医师在三级医院专家指导下进行治疗调整,以联合钙通道阻滞剂(C类药)、血管紧张素转换酶抑制剂/血管紧张素Ⅱ受体拮抗剂(A类药)、利尿药(D类药)为主要降压方案,并实施社区与三级医院间的"无缝衔接"式双向转诊模式,分析社区强化管理后患者的血压控制、用药情况及不良事件发生情况等。结果307例血压未控制患者年龄(65.0±8.6)岁,其中男性157例(51.1%),246例(80.0%)为二、三级高血压,44例(14.3%)伴糖尿病,63例(20.5%)合并临床疾病,高危、极高危患者261例(85.0%)。经社区强化达标管理(3.97±1.21)个月,患者收缩压由强化管理前的(167.56±16.73)mmHg(1mmHg=0.133kPa)降至(132.79±11.24)mmHg(t=33.34,P<0.01),舒张压由(95.34±12.59)mmHg降至(79.11±7.85)mmHg(t=23.67,P<0.01),血压达标率为75.6%(232/307);患者均无严重不良反应;经双向转诊绿色通道转上级医院共42例,转诊率13.7%,其中有6例诊断为继发性高血压。降压药物以血管紧张素Ⅱ受体拮抗剂、钙通道阻滞剂为主,在强化管理期,使用3种及以上降压药者增加158例,使用利尿剂者增加116例。结论专家指导下全科医师对高血压未控制患者的强化管理、无缝衔接式的双向转诊,以实现患者血压在社区达标,是高血压分级诊疗中一种行之有效的管理模式;社区血压未控制患者早期采用C+A、A+D及A+C+D治疗方案,可提高达标率且安全。

Objective To evaluate the effect of intensive hypertension management model for patients with uncontrolled blood pressure in community.Methods Three hundred and seven hypertensive patients,whose blood pressure was not controlled with administration of two or more kinds of antihypertensive drugs,entered in the intensive management program from May 2015 to December 2017.Using calcium channel blockers,angiotensin converting enzyme inhibitors or angiotensin receptor blockers and diuretic as the primary scheme,the medication was adjusted by general practitioners under the guidance of specialists in tertiary hospitals.The"seamless"two-way referral between community and tertiary hospitals was implemented,and the blood pressure control,medication and adverse effects were analyzed.Results Among 307 patients,157 were males(51.1%)and the mean age was(65.0±8.6)years.There were 246(80.0%)patients with moderate and severe hypertension 44(14.3%)patients complicated with diabetes,and 63(20.5%)patients having comorbidities,and the patients with high risk or extremely high-risk accounted for 85.0%(261/307).Through(3.97±1.21)months(1-6 months)intensive management,systolic blood pressure decreased from(167.56±16.73)mmHg(1 mmHg=0.133 kPa)in the baseline to(132.79±11.24)mmHg(t=33.34,P<0.01),and diastolic blood pressure from(95.34±12.59)mmHg to(79.11±7.85)mmHg(t=23.67,P<0.01),blood pressure control rate was 75.6%(232/307).No serious adverse reactions occurred.During the period 42 patients were referral to hospital through green channel with a referral rate of 13.7%,and six patients were diagnosed as secondary hypertension.Angiotensin receptor antagonists and calcium antagonists were the main antihypertensive drugs.After intensive management patients taking three or more antihypertensive drugs increased by 158 and those taking diuretics increased by 116.Conclusions The intensive management model is effective in patients with uncontrolled blood pressure in community.Early use of C+A,A+D,and A+C+D treatment schemes for uncontrolled patients in the community can improve the rate of reaching the target and is safe.