浦小弟+张喆+吴萍+陈瑛+归德兴

摘 要 目的：评价依托团队服务的社区原发性高血压患者家庭血压自我检测模式的效果。方法：选取2 0 1 4年中心建档的原发性高血压病患者1 0 0例，分为对照组和干预组。两组患者均给予常规管理：干预组另给予患者家庭血压自我检测模式干预。3年干预后，对两组的高血压知晓率、治疗依从性、血压达标率进行评价分析。结果：干预组在高血压知晓率、治疗依从性、血压控制情况均有明显的提高，与对照组相比差异有统计学意义（P<0.01）；高血压相关行为与干预前及对照组相比差异有统计学意义（P<0.01）。结论：依托团队服务的社区原发性高血压患者家庭血压自我检测模式对高血压患者的管理起到明显的效果，对社区高血压管理有推广价值。

关键词 原发性高血压 家庭血压自我检测 模式 效果

中图分类号：R544.1 文献标志码：A 文章编号：1006-1533（2016）22-0055-03

Evaluation of the effect of the establishment of self detection mode of blood pressure at patients home based on the team service for the community patients with essential hypertension

PU Xiaodi， ZHANG Zhe， WU Ping， CHEN Ying， GUI Dexing（Nanxiang Community Health Service Center of Jiading District， Shanghai 201802， China）

ABSTRACT Objective： To evaluate the effect of the self detection mode of blood pressure at patients home based on the team service for the community patients with essential hypertension. Methods： In 2014， 100 patients with essential hypertension were selected in the filing of the center and divided into a control group and an intervention group. Both groups were given the conventional management. The intervention group was given the self detection mode of blood pressure at patients home. After three years of the intervention， the awareness rate， treatment compliance and blood pressure compliance rate of the two groups were evaluated and analyzed. Results： In the intervention group， the awareness rate of hypertension， treatment compliance and blood pressure control were significantly improved， and compared with the control group， the difference was statistically significant（P<0.01）. There were statistically significant differences in hypertension related behaviors before the intervention and with the control group（P<0.01）. Conclusion： The self detection mode of blood pressure at patients home based on the team service for the community patients with essential hypertension has the obvious effect in the management of patients with hypertension and it is worth of spreading for community hypertension management.

KEY WORD essential hypertension； self detection mode of blood pressure at patients home； mode； effect

目前高血压管理主要通过系统管理、常规干预、定期随访来进行。在日常工作中发现，该管理下的居民血压控制不够稳定，对高血压认知及治疗依从性较差，因此在传统管理模式的基础上，建立了“依托团队服务的社区原发性高血压患者家庭血压自我检测模式”。

血压测量是评估血压水平、诊断高血压以及观察降压疗效的主要手段[1]。目前，在临床和人群防治工作中，主要采用诊室血压、动态血压以及家庭血压三种方法。家庭血压监测通常由被测量者自我完成，又称自测血压或家庭自测血压，也可由家庭成员等协助完成。在熟悉的家庭环境中进行测血压，可以避免白大衣效应。家庭血压监测还可用于评估数日、数周甚至数月、数年血压的长期变异或降压治疗效应，而且有助于增强患者的参与意识，改善患者的治疗依从性[1]。……