CAJ | 학술논문

目的：评价以社区管理为基础的高血压综合管理模式对防治H型高血压脑卒中的效果。方法：筛选在本院和佛山中医院三水医院、三水西南社区卫生服务中心、三水疾病防治所等医院普查、体检、门急诊、住院检出的符合条件的H型高血压患者5000例，以知情同意自愿为原则分为干预组和对照组。干预组按大医院(指导培训和重症管理)-社区医院(建档、诊疗、健康教育、随访)-家庭(关心、督促、陪伴)-患者(主动、重视、配合)的综合管理模式，按照高血压分级和危险分层实施规范化的非药物治疗+药物治疗+随访。而对照组进行常规治疗随诊，3年后评价两组患者在干预前后的管理效果。结果：经过综合干预后，干预组患者的H型高血压知识掌握率、治疗率和控制率明显上升，致残率、死亡率明显少于对照组，差异具有统计学意义(P＜0.05)。结论：以社区干预为主，综合大医院指导、家庭支持、个人配合、全社会关注等多方面的综合防治措施有利于防控H型高血压，有助于减少H型高血压所致脑卒中引起的致残、致死。
목적：평개이사구관리위기출적고혈압종합관리모식대방치H형고혈압뇌졸중적효과。방법：사선재본원화불산중의원삼수의원、삼수서남사구위생복무중심、삼수질병방치소등의원보사、체검、문급진、주원검출적부합조건적H형고혈압환자5000례，이지정동의자원위원칙분위간예조화대조조。간예조안대의원(지도배훈화중증관리)-사구의원(건당、진료、건강교육、수방)-가정(관심、독촉、배반)-환자(주동、중시、배합)적종합관리모식，안조고혈압분급화위험분층실시규범화적비약물치료+약물치료+수방。이대조조진행상규치료수진，3년후평개량조환자재간예전후적관리효과。결과：경과종합간예후，간예조환자적H형고혈압지식장악솔、치료솔화공제솔명현상승，치잔솔、사망솔명현소우대조조，차이구유통계학의의(P＜0.05)。결론：이사구간예위주，종합대의원지도、가정지지、개인배합、전사회관주등다방면적종합방치조시유리우방공H형고혈압，유조우감소H형고혈압소치뇌졸중인기적치잔、치사。
Objective:To evaluate the clinical effect of community management mode based on hypertension comprehensive management in the prevention and treatment of H type hypertension and stroke.Methods:5 000 patients with type H hypertension who were screened from survey,physical examination,outpatient and emergency department in our hospital or foshan Chinese medicine hospital,Sanshui Xi’ nan hospital,community health service center,or the Sanshui disease prevention hospital.They were divided into the intervention group and the control group based on informed consent voluntarily.The intervention group were given integrated management mode according to the big hospital(guide training and intensive management)-community hospital(file,diagnosis and treatment,health education,follow-up)-family(care,supervision,accompany)-patients(active,importance and matching),given standardized treatment of non medicine + medicine treatment + follow-up according to the grade of hypertension and risk stratification.While the control group was given conventional treatment and follow-up,3 years later, evaluate the management effect before and after the intervention in the two groups.Results:After comprehensive intervention,the knowledge rate of H type hypertensive,treatment rate and control rate in the intervention group were increased significantly,and the disability rate and mortality were significantly less than the control group.The differences were statistically significant (P<0.05).Conclusion:Community intervention based on comprehensive prevention and control measures in many aspects with the big hospital guidance,family support,personal cooperation and the attention of the whole society is helpful to the prevention and control of H type hypertension,help to reduce disability and death of stroke cause by H type hypertension.