郑淑萍王建芳初少莉袁红霞王秀灵（.上海市嘉定区真新社区卫生服务中心 上海 084；.上海交通大学附属瑞金北院 上海 0800）

专科-全科医师团队高血压患者强化管理模式效果评价*

郑淑萍1王建芳1初少莉2袁红霞1王秀灵1
（1.上海市嘉定区真新社区卫生服务中心 上海 201824；2.上海交通大学附属瑞金北院 上海 201800）

摘 要目的：探讨在全科医师团队服务制度下，专科-全科医师团队高血压患者强化管理模式对社区高血压管理的效果。方法：选取上海嘉定区真新街道社区卫生服务中心高血压控制不佳患者150例，通过专科-全科医师团队对高血压患者进行强化管理，3个月后评估患者血压水平的控制情况，并与管理前进行比较。结果：与强化管理前相比，高危和极高危组患者比例从86.7%（130例）下降至40.7%（61例），平均收缩压从(170±11.6)mmHg（1 mmHg=0.133 kPa）下降至(132.8±7.2)mmHg，平均舒张压从(101.6±8.8)mmHg下降至(82.8±7.2)mmHg，患者依从性从75.3%（113例）上升至98.7%(148例)，差异均有统计学意义(P均＜0.05)。结论：专科-全科医师团队高血压患者强化管理模式有利于提高患者血压控制率和改善患者心血管危险因素分层。

关键词高血压 治疗 全科医师 强化管理模式

*基金项目：上海市卫生和计划生育委员会基金资助（201540014）；上海市中西医结合学会优秀课题（SH201404）

Evaluation of the effect of the reinforcing management model of the specialist-general practitioner team on the hypertension patients

ZHENG Shuping1, WANG Jianfang1, CHU Shaoli2, YUAN Hongxia1, WANG Xiuling1
(1.Zhenxin Community Health Service Centre of Jiading District, Shanghai 201824, China; 2.Ruijin Hospital North, School of Medicine of Shanghai Jiao Tong University, Shanghai 201800, China)

ABSTRACTObjective: To explore the community hypertension management effect of the reinforcing management model of the specialist-general practitioner team under the general practitioner service system on the hypertension patients. Methods: In Zhenxin Community Health Service Center of Jiading District in Shanghai, 150 hypertension patients with the unsatisfied therapeutic effect were selected and managed intensively through the specialist-general practitioner team. After 3 months, the control of the blood pressure levels of the patients was evaluated and compared with it before the management. Results: Among 150 patients, the ratio of the patients in the high-risk group and extremely high-risk one was reduced from 86.7% (130 cases) before the reinforcing management to 40.7% (61 cases). The average systolic pressure was dropped from (170±11.6)mmHg before the reinforcing management to (132.8±7.2)mmHg, while the average diastolic pressure was also dropped from (101.6±8.8) mmHg to (82.8±7.2)mmHg. The compliance of the patients rose from 75.3% (113) to 98.7% (148), and all the difference had the statistical significance (P＜0.05). Conclusion: The reinforcing management model of the specialist-general practitioner team on the hypertension patients is beneficial to enhancing the blood control rate and improving the stratification of cardiovascular risk factors in the patients.

KEY WORDShypertension; treatment; general practitioner; reinforcing management model

高血压病是心脑血管疾病的危险因素，我国高血压病患者超过2亿[1]，控制血压可有效减少心脑血管事件的发生。目前认为社区是控制高血压的主战场[2]。上海市嘉定区真新街道社区卫生服务中心自2010年开始对高血压患者进行……