基于立体化、全过程管理的高血压和糖尿病防治体系构建与实践研究

Research on the Implementation and Practice of the Three-dimensional and Total Process Managed Prevention and Control System of Hypertension and Diabetes

目的构建、实施立体化、多手段和全过程管理的高血压和糖尿病防控体系。方法自2013年起,深圳市福田区把高血压和糖尿病防-治-管融为一体,建立高血压和糖尿病专科联盟,实施全过程健康管理和有序的分级诊疗;建立"福田区健身房""智能健康教育平台"和"健康福田微信公众号"等;开展"互联网+"高血压和糖尿病健康管理。结果构建立体化、多手段和全过程管理的高血压和糖尿病防治体系,福田区高血压、糖尿病管理人数稳步上升,截至2018年6月,纳入管理的高血压和糖尿病患者分别有46 187人和18 390人,规范管理率分别为75.50%和76.53%,血压、血糖达标率分别为69.59%和66.61%;居民的生活行为得到明显改善,居民对重点慢性病核心知识知晓率达到67.8%,居民健康素养水平达到21.6%。结论福田区构建的立体化、多手段和全过程高血压和糖尿病防治体系运行效果满意,能够有效提升社区高血压和糖尿病的管理效果,值得推广应用。

OBJECTIVE To build and implement three-dimensional, total process managed prevention and control system of hypertension and diabetes. METHODS The control and management network for hypertension and diabetes prevention, had been established since 2013, in which the hypertension and diabetes alliance was found while the whole-process health management and hierarchical diagnosis were implemented. It built the"Futian Gym"and"Intelligent Health Education Platform"and"Health Futian Wechat Official Accounts", built a healthy life related website and app. Moreover, internet-based health management for hypertension and diabetes was implemented by family doctor groups. RESULTS The effect of hypertension management was obviously improved for the hypertension, diabetes prevention and control system in Shenzhen Futian, China. By the end of June 2018,46 187 hypertension patients and 18 390 diabetes patients were managed, the rate of standardized management were 75.50% and 76.53%, the control rate of blood pressure and blood sugar were 69.59% and 66.61%. Residents’ life behavior had been significantly improved. The awareness rate of chronic diseases was 67.8%. and the health literacy level reached 21.6%. CONCLUSION It was satisfactory to improve the three-dimensional,total process managed prevention and control system of hypertension and diabetes in Shenzhen, which was worth extending to other place in China.