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目的评价江苏省淮安市高血压患者社区规范化管理效果。方法在社区为筛查出的17 559例高血压患者建立高血压专项管理档案,由经过规范化培训的基层社区医生对其进行临床评估,根据危险程度,实行分级分层随访、规范管理。结果经过社区规范化管理后,高血压患者平均收缩压和舒张压分别降低16.56和8.97 mmHg(1mmHg=0.133 3 kPa);高血压患者知晓率、治疗率、血压控制率、服药控制率由一年前的83.53%,66.20%,3.93%和4.42%分别上升至100%,99.40%,38.73%和41.81%(P<0.01);2级和3级高血压由50.01%降低到10.94%;对2822例随访管理时间较长的患者血压水平进行重复测量的方差分析结果显示,随着管理次数的增加收缩压、舒张压均呈下降趋势(P<0.01)。结论社区规范化管理能有效改变高血压患者的不良生活方式,提高服药依从性,良好控制血压、减少并发症,提高生命质量。社区综合防治是提高高血压人群防治效果的有效途径。
Objective To evaluate the effect of standardized management of hypertensive patients in Huaian City, Jiangsu Province. Methods A total of 17 559 hypertensive patients screened out in the community were set up to manage hypertension. The grassroots community doctors who had undergone standardized training were evaluated clinically. According to the degree of risk, they were graded and followed up with standardized management. Results After community standardized management, the average systolic and diastolic blood pressure in hypertensive patients decreased by 16.56 and 8.97 mmHg (1mmHg = 0.133 3 kPa) respectively. The awareness rate, treatment rate, blood pressure control rate and medication control rate in patients with hypertension increased from one year ago The levels of Grade 2 and Grade 3 hypertension decreased from 50.01% to 10.94%, while the levels of 83.53%, 66.20%, 3.93% and 4.42% increased to 100%, 99.40%, 38.73% and 41.81% Analysis of variance (ANOVA) for repeated measurements of blood pressure levels in patients with long follow-up showed that systolic and diastolic blood pressure decreased with increasing management frequency (P <0.01). Conclusion Community-based management can effectively change the unhealthy life style of hypertensive patients, improve medication compliance, control blood pressure, reduce complications and improve quality of life. Comprehensive community control is to improve the prevention and treatment of hypertension in an effective way.