CAJ | 학술논문

目的：观察社区高血压患者实施健康管理后的效果。方法三级综合医院与某社区合作共同对该社区1420例高血压患者进行系统规范的综合干预及健康教育，建立完善的健康管理档案，实施1年后对患者进行问卷调查。结果健康管理后患者对高血压诊断标准、高血压病并发症、高血压药物治疗方法和转诊要求的知晓率均高于健康管理前，差异有统计学意义(均P<0.05)；健康管理后患者生活方式改善，高血压危险因素减少，高血压知晓率、治疗率、达标率得到提高，差异有统计学意义(P<0.05)。结论综合医院与社区医院合作共同管理社区高血压人群，可以合理利用医疗资源，提高基层医务人员慢病管理水平，提高社区高血压控制达标率，降低致残率和死亡率，减少医疗费用，改善生活质量。
목적：관찰사구고혈압환자실시건강관리후적효과。방법삼급종합의원여모사구합작공동대해사구1420례고혈압환자진행계통규범적종합간예급건강교육，건립완선적건강관리당안，실시1년후대환자진행문권조사。결과건강관리후환자대고혈압진단표준、고혈압병병발증、고혈압약물치료방법화전진요구적지효솔균고우건강관리전，차이유통계학의의(균P<0.05)；건강관리후환자생활방식개선，고혈압위험인소감소，고혈압지효솔、치료솔、체표솔득도제고，차이유통계학의의(P<0.05)。결론종합의원여사구의원합작공동관리사구고혈압인군，가이합리이용의료자원，제고기층의무인원만병관리수평，제고사구고혈압공제체표솔，강저치잔솔화사망솔，감소의료비용，개선생활질량。
Objective: To evaluate the effect of health management for community hypertension patients. Method: The third-level general hospital cooperation with the community together carried out comprehensive intervention and health education system specification for the 1420 cases of hypertension patients in community, established a perfect health management archives, the patients were investigate with questionnaire after 1 year. Result: After the health management, the patients, knowledge of hypertension diagnosis standard, hypertension complications, drug treatments and referral request were higher than before (P<0.05). After the health management, the patients’ way of life was improved, the risk factors for hypertension decreased, awareness rate, treatment rate, control rate of hypertension increased(P<0.05). Conclusion: General hospital and community hospital together managed community hypertension patients can reasonably utilize medical resources, improve the basic medical staff of chronic disease management, improve the community hypertension control rate ,reduce the morbidity and mortality, reduce the cost of medical care, improve the quality of life.