上海市某社区门诊患者高血压管理现况分析

Analysis of Hypertension Management among Outpatients in a Community in Shanghai

目的分析上海市打浦桥社区高血压管理现况,为完善社区高血压人群规范管理提供依据。方法于2019年11月通过对上海市黄浦区打浦桥社区卫生服务中心HIS系统、上海市健康委员会“综合改革云管理平台”、上海市疾病预防控制中心“基于市民电子健康档案的卫生信息化工程疾病预防控制信息系统社区高血压管理平台”、上海市黄浦区疾病预防控制中心等多个渠道,调取目前上海市黄浦区打浦桥社区门诊患者签约和高血压管理情况数据。借助SPSS 24.0软件进行数据分析。结果门诊就诊的9584例高血压患者中,纳入社区高血压管理的有4449例(46.4%)。签约情况、高血压管理情况、测压数据等信息齐全的4547例门诊就诊患者中,有高血压者3735例(82.1%),无高血压者812例(17.9%)。其中,签约和未签约的无高血压患者在性别、年龄、2017~2018年就诊次数和全科就诊次数上的差异均有统计学意义(P<0.05);签约和未签约的高血压患者在年龄、2017~2018年就诊次数和全科就诊次数上的差异均有统计学意义(P<0.05);纳入和未纳入社区高血压管理的高血压患者,在年龄、血压异常情况、2017~2018年就诊次数和全科就诊次数上的差异均有统计学意义(P<0.05)。结论社区门诊高血压患者管理率较低,可能是高血压管理信息共享不充分、高血压管理统计口径不完善所致。“1+1+1”签约和社区高血压管理对社区高血压相关人群的就诊行为有显著的引导社区就医的特点,但在血压异常率控制方面,签约所能产生的效果尚不明确,而社区高血压管理则能显著降低血压异常率。区域高血压管理信息共享和高血压管理统计口径等仍有待完善,以提升社区高血压管理效率。

Objective To analyze the current status of hypertension management of community outpatient populations,so as to provide a basis for improving the standardized management of community hypertension populations.Methods In November 2019,through the HIS system of Dapuqiao Community Health Service Center in Huangpu District of Shanghai,Shanghai Health Committee's“Comprehensive Reform Cloud Management Platform”,Shanghai Center for Disease Prevention and Control's“Community Hypertension Management Platform of Health Information Engineering Disease Prevention and Control Information System Based on Citizen Electronic Health Records”,Shanghai Huangpu District Center for Disease Prevention and Control and other channels,the data of outpatient contracts and hypertension management in Dapuqiao Community in Huangpu District of Shanghai were collected.SPSS 24.0 software was used for data analysis.Results Of the 9584 outpatients with hypertension,4449(46.4%)were included in community hypertension management.Among the 4547 outpatients with complete information such as signing,hypertension management and pressure measurement data,3735(82.1%)had hypertension and 812(17.9%)had no hypertension.Among them,the differences in gender,age,the number of visits from 2017 to 2018 and the number of general visits between contracted and non-contracted patients without hypertension were statistically significant(P<0.05).There were significant differences in age,number of visits from 2017 to 2018 and number of general visits between contracted and non-contracted hypertensive patients(P<0.05).There were statistically significant differences in age,abnormal blood pressure,number of visits from 2017 to 2018 and number of general visits between hypertensive patients with and without community hypertension management(P<0.05).Conclusion The low management rate of hypertension patients in community clinics may be due to insufficient information sharing and imperfect statistical caliber of hypertension management.“1+1+1”contract and community hypertension management have significant characteristics of guiding community medical treatment for hypertension-related people in the community.However,the effect of contract on the control of abnormal blood pressure rate is not clear,and community hypertension management can significantly reduce the abnormal blood pressure rate.Regional hypertension management information sharing and hypertension management statistics caliber still need to be improved to improve the efficiency of community hypertension management.