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目的:摸索一套适宜农村社区“规范化、规模化和信息化”的高血压社区综合干预管理模式。方法:按照《浙江省高血压社区综合干预信息化管理》(简称《规范》)实施方案,采用省心脑血管病防治中心专门指定的高血压防治管理系统(gxy.u1000.net),对辖区内≥18岁的户籍居民进行健康基线调查,对社区责任医生培训,按结果将调查对象分为一般人群、高危人群和高血压患者,按血压水平和危险因素分布,实施社区人群的高血压分类管理和综合干预。结果:该社区居民高血压治疗率、控制率和知晓率有明显上升,高危人群各类危险因素明显下降。结论:在农村社区实施高血压社区综合干预信息化管理是切实可行的。
Objective: To explore a suitable rural community “standardization, scale and information ” hypertension community intervention management model. Methods: According to the Implementation Plan of Information Management of Hypertension Community Intervention in Zhejiang Province (referred to as “Specification”), the hypertension prevention and control management system (gxy.u1000.net) specially designated by Provincial Center for Cardiovascular and Cerebrovascular Diseases was used. Within the age of 18-year-old residents to carry out a healthy baseline survey of health care, community responsibility doctors training, according to the results of the survey will be divided into the general population, high-risk groups and patients with hypertension, according to blood pressure levels and risk factors distribution, the implementation of community-based hypertension classification Management and comprehensive intervention. Results: Hypertension treatment rate, control rate and awareness rate of residents in this community were significantly increased, and all kinds of risk factors in high-risk population were significantly decreased. Conclusion: It is practicable to implement the information management of comprehensive intervention in hypertensive community in rural communities.