基于慢病管理路径的社区高血压患者管理效果评价

Effect evaluation of community hypertension patients'management based on chronic disease management pathway

目的评估基于慢病管理路径对社区高血压患者实施健康管理的有效性。方法选取2019年1—6月郑州市2个辖区内高血压患者160名,采用随机数表法将其分为管理组和对照组,各80名,分别接受为期1年的基于慢病管理路径的管理和社区常规管理,1年后评估患者血压控制情况、体重指数、高血压预防知识掌握情况、药物依从性以及患者对管理方案的接受度。结果最终共入组患者154例,其中管理组78例,对照组76例。管理1年后,2组患者收缩压、舒张压均显著下降(均P<0.05),血压达标率均得到了显著提升,管理组优于对照组(60.2%vs.42.1%,P<0.05)。管理组患者在危险因素和预警症状2个方面的知识掌握人数高于对照组,差异有统计学意义(P<0.05)。2组患者在管理后药物依从性均有明显改善(t=4.463,P<0.001;t=3.525,P=0.001)。问卷调查显示,88.5%(69/78)的入组患者表示该管理方案具有一定的实用性,94.9%(74/78)的入组患者希望继续使用此方案进行慢病的管理。结论基于慢病管理路径的综合管理可以改善社区高血压患者的血压控制率和达标率,提高其依从性,且有助于高血压患者掌握相关的预防知识。

Objective To evaluate the effectiveness of health management for hypertension patients in the community based on the chronic disease management pathway.Methods A total of 160 patients with hypertension in two districts of Zhengzhou City from January 2019 to June 2019 were selected and divided into management group and control group by random number table,with 80 cases in each group.They received one-year management based on chronic disease management pathway and community routine management,respectively.After one year,blood pressure control,BMI,hypertension prevention knowledge,drug compliance and patients'acceptance of the management plan were evaluated.Results A total of 154 patients were enrolled,including 78 patients in the management group and 76 patients in the control group.After one year,systolic blood pressure(SBP)and diastolic blood pressure(DBP)of the two groups were significantly decreased(all P<0.05),and the blood pressure compliance rate was significantly improved,while the management group was better than the control group(60.2%vs.42.1%,P<0.05).The number of patients in the management group who mastered the knowledge of risk factors and early warning symptoms was higher than that in the control group,with a statistically significant difference(P<0.05).The drug compliance of the two groups was significantly improved(t=4.463,P<0.001;t=3.525,P=0.001).The questionnaire survey showed that 88.5%(69/78)of the enrolled patients said that the management scheme had certain practicability,and 94.9%(74/78)of the enrolled people hoped to continue to use the scheme for chronic disease management.Conclusion Comprehensive management based on chronic disease management pathways can improve the blood pressure control rate and compliance rate of community hypertension patients,and help hypertension patients master relevant prevention knowledge.