摘要
目的了解社区责任医生团队服务模式对高血压社区管理的效果。方法以社区责任医生团队服务模式对纳入管理的高血压患者进行规范化管理,比较与以往医、护、防分隔管理模式在高血压筛检率、管理率、控制率、高血压相关疾病发病率等方面的变化情况。结果 35岁以上者首诊测血压率由2006年的34%上升至2009年的88%,高血压人群登记发病率由4.3%上升至7.1%,高血压规范化管理率由72.1%上升至96.7%,血压控制不良率由63.0%降至32.0%,急性事件发生例数由60例下降至38例。高盐饮食、缺乏运动、吸烟、酗酒等高血压危险因素分别下降19.17%、11.03%、8.60%、16.85%。结论社区责任医生团队对高血压患者实施全程、连续、综合性的管理,患者依从性提高,高血压社区管理效率明显提升。
Objective To understand the better effect of the team service model of community doctors who were responsible for the community management of hypertensive patients. Methods The hypertensive screening rate,management rate,control rate and the incidence of related diseases were investigated for hypertension patients had received the team services by community doctors with the standardized management,as compared with the traditional separate management model of doctors,nurses,and preventive health care. Results The blood pressure test rate of the patients aged more than 35 at the first visit increased from 34% in 2006 to 88% in 2009.The rate of the registered hypertensive incidence rose from 4.3% to 7.1%;and the rate of standardized management rose from 72.1% to 96.7%.The poor control rate of the hypertensive decreased from 63.0% to 32.0%.The number of the hypertensive emergency reduced from 60 to 38.The hypertension risk factors of high-salt diet,lack of exercise,smoking,and alcoholism declined by 19.17%,11.03%,8.60% and 16.85% respectively. Conclusion The throughout,continuous and integrated management of hypertension given by responsible doctor team for hypertensive patients can improve the hypertensive compliance and thus significantly raise the hypertension community management efficiency.
出处
《中国全科医学》
CAS
CSCD
北大核心
2011年第4期405-407,共3页
Chinese General Practice
关键词
社区责任医生团队
高血压
慢病管理
The community doctors team
Hypertension
Chronic disease management
