家庭医生“1+1+1”组合签约服务对社区老年居民高血压管理效果的影响

Effect of general practitioner“1+1+1”combo mode on disease management of elderly hypertensive patients in the community

目的探讨家庭医生“1+1+1”组合签约模式对社区老年高血压病患者疾病管理的效果。方法以2016年在安亭镇社区卫生服务中心建立居民电子健康档案并进行管理的高血压人群为研究对象,按照是否接受家庭医生“1+1+1”组合签约管理分为签约组(n=1538)和非签约组(n=2437),进行1年的随访观察。结果两组居民入组时,签约组吸烟人数,每周锻炼次数及每次锻炼时间低于未签约组(P<0.05)。经过1年的签约管理,签约组患者腰围平均减少0.36(0.06,0.66)cm,脉压差平均降低3(-3.77,-2.23)mmHg,显著优于非签约组患者(P<0.05)。签约组患者新发糖尿病67例,显著高于非签约组(P=0.002),新发中风62例,显著低于非签约组(P=0.001)。校正吸烟及每周锻炼次数后,多因素回归结果显示,签约管理可以显著降低中风发生的风险[adjust odds ratio(AOR)=0.668,95%CI 0.449~0.895],同时不会增加糖尿病的发生风险(AOR=1.642,95%CI 0.936~2.882)。结论家庭医生“1+1+1”组合签约管理模式可有效降低社区老年高血压患者中风发生风险,对社区老年高血压患者疾病管理效果优于传统慢性病管理模式,家庭医生“1+1+1”组合签约管理模式是一种值得推广的方式。

Objective To investigate the effect of general practitioner“1+1+1”combo mode on disease management of elderly hypertensive patients in the community.Methods The hypertensive residents in Shanghai Anting Town with the electronic health records in the community health service center were enrolled in 2016.Among all participants,1538 individuals received“1+1+1”combo model for disease management(management group)and 2437 individuals received convenient management(control group).After one-year follow-up,adverse outcomes associated with hypertension were evaluated and compared between two groups.Results The number of smokers,the frequency of exercise per week,and the duration of exercise in the management group were lower than those in the control group at baseline(P<0.05).After 1 year of intervention,the waist circumference,and pulse pressure difference of patients in the management group decreased by 0.36(0.06,0.66)cm and 3(-3.77,-2.23)mmHg on average respectively(All P<0.05).The improvement in these parameters were significantly better than those of the control group(P<0.05).As for newly-emerged adverse events,67 patients in the management group had new-onset diabetes,which was significantly higher than that in the control group(P=0.002);however,62 patients in the management group had new-onset strokes,which was significantly lower than that in the control group(P=0.001).After adjusting for smoking and weekly exercise frequency,multivariate regression showed that contract management significantly reduced the risk of stroke[adjust odds ratio(AOR)=0.668,95%CI 0.4490.895],but did not increase the risk of diabetes(AOR=1.642,95%CI 0.9362.882).Conclusion The general practitioner“1+1+1”combo medical care management mode can effectively reduce the risk of stroke in elderly hypertensive patients in the community,and the effect is better than that of the traditional management mode.This primary medical care mode is worth promoting.