欧阳雷+陈良+高文妹

摘 要 目的：评价家庭医生和二级医院专科联动对高血压患者管理的效果。方法：选取凌云街道社区卫生服务中心2015年1—3月新纳入管理的高血压患者285例，分为精细化管理组99例，采用家庭医生和二级医院专科联动模式进行管理；一般管理组186例，采用传统高血压管理模式进行管理，对两组患者血压值、达标率、高血压防治知识知晓率进行比较。结果：干预后，两组患者的收缩压、舒张压、达标率比较差异均有统计学意义（P<0.05）；精细化管理组患者的高血压防治知识知晓率较一般管理组提高更明显，差异有统计学意义（P<0.05）。结论：采用家庭医生和二级医院专科联动对社区高血压患者实施管理，可显著改善患者的管理效果。

关键词 高血压 家庭医生 二级医院 效果评价

中图分类号：R544.1 文献标志码：A 文章编号：1006-1533（2016）22-0052-03

Evaluation of the effect of linkage mode between the family doctor and the specialty department of the second grade hospitals in the management of the hypertension patients

OUYANG Lei1， CHEN Liang1， GAO Wenmei2（1. Lingyun Community Health Service Centre of Xuhui District， Shanghai 200237， China； 2.Dahua Hospital of Xuhui District， Shanghai 200237， China）

ABSTRACT Objective： To evaluate the effect of linkage between the family doctor and the specialty department of the second grade hospitals in the management of the hypertension patients. Methods： Totally 285 patients with hypertension who were newly included in Lingyun Community Health Service Centre were divided into a delicacy management group with 99 cases and managed with the linkage mode between the family doctor and the specialty department of the second grade hospitals and a general management group with 186 cases and managed with the traditional hypertension management mode. The blood pressure value， blood pressure attainment rate and patients awareness rate of hypertension prevention and control knowledge were compared between the two groups. Results： After the intervention， the differences in systolic and diastolic blood pressures and blood pressure attainment rate had the statistical significance between the two groups（P<0.05）. The awareness rate of hypertension prevention and control knowledge was higher in the delicacy management group than that in the general management group（P<0.05）. Conclusion： The community hypertension patients are managed with the linkage mode between the family doctor and the specialty department of the second grade hospitals can remarkably improve the effectiveness of the management of the patients with hypertension.

KEY WORDS hypertension； family doctor； second grade hospital； effect evaluation

高血压是我国人群脑卒中和冠心病发病及死亡的主要危险因素，而我国心脑血管死亡约占总死亡人数的一半。大量高血压大型随机临床试验已充分说明降压可减少心血管并发症发生率和死亡率，因此控制高血压是预防心脑血管事件的关键[1]。本文旨在评价采用社区家庭医生与二级综合医院专科联动的精细化管理模式对控制高血压患者血压的效果。

1 对象与方法

1.1 对象

本研究对象为凌云街道社区卫生服务中心2015年1—3月新纳入管理的高血压患者。入选标准：血管危险分层为中危或高危或很高危者，新诊断需服药或已服药但血压控制不佳。排除标准：低危者、血压已控制良好者、已明确的继发性高血压患者。符合入选标准和排除标准的共285例，其中选取一个团队管辖的99例采用精细化管理模式，另外两个团队管辖的186例仍采取原先的一般管理模式。……