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目的:了解该社区高血压的慢病管理现状,为在本社区中有效地开展高血压防治工作提供依据。方法:选取本社区中200名原发性高血压患者的基本情况及随访12个月的血压控制率、药物使用及调整情况、生活方式与接受管理程度等情况进行统计调查。结果:经过系统管理患者依从性从管理前的78.5%提高到97.5%,知晓率也从原来的70%提高到97%,体重有所减轻的患者达到164人,能坚持以各种方式进行适当运动人数达到125人,大部分患者均能按时预约进行健康体检及随访,92.32%的患者能完全配合医生的管理。结论:本社区中高血压的整体治疗率和控制率均较高,以社区为中心的慢病管理模式在高血压防治工作中可以起到良好作用。
OBJECTIVE: To understand the status of chronic disease management in hypertension in this community and provide the basis for effective prevention and treatment of hypertension in this community. Methods: The basic situation of 200 patients with essential hypertension in this community and the follow-up of 12 months of blood pressure control rate, medication use and adjustment, lifestyle and acceptance of the degree of statistical investigation. Results: Systemically managed patient adherence increased from 78.5% pre-management to 97.5%, awareness rate increased from 70% to 97%, weight loss decreased to 164 and persevered in various ways The number of exercise reached 125 people, most of the patients can make a scheduled physical examination and follow-up on time, 92.32% of patients can fully cooperate with the doctor’s management. Conclusion: The overall treatment rate and control rate of hypertension in this community are high. The community-centered chronic disease management mode can play a good role in the prevention and treatment of hypertension.