CAJ | 학술논문

目的：探讨二级医院与社区健康服务中心（社康中心）互动式管理在社区高血压患者健康管理中的应用及效果。方法选择深圳市宝安区西乡人民医院及其所属的35家社康中心和深圳市第七人民医院及其所属的5家社康中心作为现场试点，进行为期1年（2011年12月-2012年11月）的健康管理。其中将实施与医院互动式管理的17家社康中心作为观察组，其他未实施与医院互动式管理的23家社康中心作为对照组。通过文献研究、专家咨询制定互动式管理路径，通过试点对互动式管理模式进行验证及修改。比较健康管理前后两组患者健康管理意识及依从性变化，并分析两组患者健康管理质量。结果管理前两组患者中遵医嘱用药、主动要求管理及参加自我管理小组者所占比例比较，差异均无统计学意义（ P﹥0.05）；管理后观察组患者中遵医嘱用药、主动要求管理及参加自我管理小组者所占比例高于对照组（P﹤0.05）。观察组不良行为改变率、规范管理率及血压控制率均高于对照组（P﹤0.05）。结论二级医院与社康中心互动式管理模式能有效提高社区高血压患者管理依从性及管理质量，适宜推广。
목적：탐토이급의원여사구건강복무중심（사강중심）호동식관리재사구고혈압환자건강관리중적응용급효과。방법선택심수시보안구서향인민의원급기소속적35가사강중심화심수시제칠인민의원급기소속적5가사강중심작위현장시점，진행위기1년（2011년12월-2012년11월）적건강관리。기중장실시여의원호동식관리적17가사강중심작위관찰조，기타미실시여의원호동식관리적23가사강중심작위대조조。통과문헌연구、전가자순제정호동식관리로경，통과시점대호동식관리모식진행험증급수개。비교건강관리전후량조환자건강관리의식급의종성변화，병분석량조환자건강관리질량。결과관리전량조환자중준의촉용약、주동요구관리급삼가자아관리소조자소점비례비교，차이균무통계학의의（ P﹥0.05）；관리후관찰조환자중준의촉용약、주동요구관리급삼가자아관리소조자소점비례고우대조조（P﹤0.05）。관찰조불량행위개변솔、규범관리솔급혈압공제솔균고우대조조（P﹤0.05）。결론이급의원여사강중심호동식관리모식능유효제고사구고혈압환자관리의종성급관리질량，괄의추엄。
Objective To explore the application and effect of interactive management between secongery hospitals and community health service centers on health management in community hypertensive patients. Methods Xixiang People's Hospi-tal of Baoan District,Shenzhen and its presidial 35 community health service centers,the Seventh People 's Hospital of Shenzhen and its presidial 5 community health service centers were chosen as a pilot site,and carried out health management for 1 year ( from December 2011 to November 2012 ) . 17 community health service centers implemented interactive management were served as observation group,the other 23 community health service centers did not implemented interactive management as control group. Literature research and expert consulting were used to formulate a interactive management path,pilot study was used to verify the applicability of the interactive management model. The health management awareness and compliance before and after management were compared,and the quality of health management was analyzed. Results There was no significant differences of the proportions of prescribed medication,initiatively required management and acceding self-management groups between the two groups before management(P﹥0. 05);the proportions of prescribed medication,initiatively required management and ac-ceding self-management groups of observation group were higer than those of control group after management(P﹤0. 05). The change rate of bad behavior,rate of standardized management and blood pressure control rate of observation group were higher than those of control group(P﹤0. 05). Conclusion The interactive management between secongery hospitals and community health service centers can effectively improve the compliance and quality of health management in community hypertensive pa-tients,is worthy of promotion.