CAJ | 학술논문

目的评价以家庭为单位联合社区医疗网络对高血压病进行群体管理和个人管理相结合防治模式的管理效果.方法以三水西南街道康华、布心、沙头、园林、文峰东等5个居委为主要试点,在知情同意的基础上筛选检出的原发性高血压个体300例,共300户家庭,按照综合医院负责指导培训和高血压重症管理;社区医院负责轻中症管理、建档、健康教育、随访、转诊;高血压群组和家庭成员互相协助、配合、督促的综合管理模式,登记、注册、建卡、建立高血压档案,对病患及其主要家庭成员家属进行健康教育,通过群组和家庭成员督促病者按时服药、就诊复查及改变吸烟、饮酒、过激、过劳等不良生活习惯,建立可行的个体化长期诊疗方案,随访观察1年后评价患者在干预前后的管理效果.结果经过以家庭为单位的各级医疗网络联合干预后,患者的高血压知识掌握率明显提高,高血压知晓率从39.0％提高到99.0％、治疗率从65.0％提高到99.0％,控制率从22.7％提高到80.3％.吸烟、喝酒、高盐高脂饮食等高血压危险因素和血压值明显下降,新增心脑血管事件及其所致的致残率、死亡率均无明显增加,治疗费用从每周(27.17±6.44)元降至每周(11.48±2.85)元.结论建立以综合医院为指导,社区医院负责轻中症治疗、随访、宣教,高血压群组和家庭成员互相协助、配合、督促,群体管理和个人自我管理相结合的综合医院-社区医院-高血压家庭群组/家庭户-个人的管理模式能对高血压病进行有效管理.
목적 평개이가정위단위연합사구의료망락대고혈압병진행군체관리화개인관리상결합방치모식적관리효과.방법 이삼수서남가도강화、포심、사두、완림、문봉동등5개거위위주요시점,재지정동의적기출상사선검출적원발성고혈압개체300례,공300호가정,안조종합의원부책지도배훈화고혈압중증관리;사구의원부책경중증관리、건당、건강교육、수방、전진;고혈압군조화가정성원호상협조、배합、독촉적종합관리모식,등기、주책、건잡、건립고혈압당안,대병환급기주요가정성원가속진행건강교육,통과군조화가정성원독촉병자안시복약、취진복사급개변흡연、음주、과격、과로등불량생활습관,건립가행적개체화장기진료방안,수방관찰1년후평개환자재간예전후적관리효과.결과 경과이가정위단위적각급의료망락연합간예후,환자적고혈압지식장악솔명현제고,고혈압지효솔종39.0％제고도99.0％、치료솔종65.0％제고도99.0％,공제솔종22.7％제고도80.3％.흡연、갈주、고염고지음식등고혈압위험인소화혈압치명현하강,신증심뇌혈관사건급기소치적치잔솔、사망솔균무명현증가,치료비용종매주(27.17±6.44)원강지매주(11.48±2.85)원.결론 건립이종합의원위지도,사구의원부책경중증치료、수방、선교,고혈압군조화가정성원호상협조、배합、독촉,군체관리화개인자아관리상결합적종합의원-사구의원-고혈압가정군조/가정호-개인적관리모식능대고혈압병진행유효관리.
Objective To evaluate the effect of hypertension prevention and cure pattern which combines group management and individual management by family-unit and community medical network.Methods 300 patients with essential hypertension from 300 families of residents committees such as Kanghua,Buxin,Shatou,Yuanlin,Wenfengdong,were trained and managed under general hospitals by informed consent.The community hospitals took the responsibility for management,establishing files,health education,followup and referral of mild and moderate cases.Patients took medicine,had subsequent visits,and changed bad habits such as smoking,drinking,superexcitation and overwork with the help of their families.Individual long-term diagnosis and treatment schemes were implemented.Evaluated the interference effect after 1 year.Results The rates of awareness,treatment and control increased significantly (39.0％ vs.99.0％,65.0％ vs.99.0％,22.7％ vs.80.3％).The risk factors of hypertension such as smoking,drinking,high-salt and highfat diet,and blood pressure presented the downward trend after comprehensive interference.The new onset of cardiovascular and cerebrovascular events and their disability rate and mortality didn' t increase obviously.The cost of treatment decreased [(27.17 ± 6.44)yuan per week vs.(11.48 ± 2.85)yuan per week].Conclusions The general hospital-community hospital-group-individual management mode which is guided by general hospital,and is responsible for treatment by community hospital can manage hypertension more effectively.Under this mode,follow-up and education of mild and moderate cases are helped with families with integrity of group management and individual management.