基于信息化的家庭医生团队预约随访模式管理高血压的效果评价

Evaluation of the effect of the information-based family doctor team appointment follow-up mode in the management of hypertension

目的:评价家庭医生团队信息化预约随访管理模式的效果。方法:将2017年8月至10月在上海方松街道社区卫生服务中心签约316例原发性高血压患者随机分为干预组(162例)和对照组(154例)。干预组患者实行家庭医生团队预约就诊、信息化平台数据反馈、家庭医生工作室随访等管理模式,提供持续规范的诊疗服务;对照组患者实行全科门诊及电话随访、健康讲座等常规管理模式。比较干预1年后的管理效果。结果:随访1年后,干预组的钠盐管理率、运动管理率以及血压、血糖、低密度脂蛋白胆固醇控制水平均优于对照组(P均<0.05)。结论:基于信息化的家庭医生团队预约随访管理模式可提高社区高血压管理效果。

Objective: To evaluate the effect of the informationized appointment follow-up management mode of the family doctor team. Methods: A total of 316 patients with essential hypertension signed by Fangsong Community Health Service Center from August to October 2017 were randomly divided into an intervention group with 162 cases and a control group with154 cases. The patients of the intervention group implemented the medical appointment of family doctor team, information feedback of information platform, and follow-up of family doctors’ studios and other management mode to provide continuous and standardized medical services;the patients of the control group were given routine management mode of general outpatient service, telephone follow-up and health lecture. The management effect after 1 year intervention was compared. Results: After1 year of follow-up, the sodium salt management rate, exercise management rate, and blood pressure, blood glucose, and lowdensity lipoprotein cholesterol control levels of the intervention group were superior to those of the control group(P<0.05).Conclusion: The information-based family doctor team appointment follow-up management mode can improve the community hypertension management effect.