家庭医生团队式服务对社区高血压患者干预效果评价

　　【摘要】 目的：探討家庭医生团队式服务对社区高血压患者的干预效果，为社区高血压患者管理模式提供理论依据。方法：选取2015-2016年度深圳市光明新区经医院或社区健康服务中心确诊的高血压患者276例，患者均接受家庭医生团队式服务。比较患者接受服务前和服务满1年后的高血压KAP调查结果、血压（收缩压、舒张压），统计分析患者服务前后的高血压知晓率、治疗率、控制率、药物控制率并与国内10个地区人群标化率进行比较。结果：服务后，患者高血压知识掌握方面均优于服务前（P<0.01）；看待高血压的态度方面，仅“患高血压后应每天坚持适量运动”优于服务前（P<0.01），其他态度项目比较均无统计学意义（P>0.05）；从行为转变方面，定期监测血压和坚持运动方面均优于服务前（P<0.05），其他行为转变项目比较均无统计学意义（P>0.05）。服务后，患者收缩压、舒张压均较服务前降低，比较差异均有统计学意义（P<0.01）。服务前，患者的知晓率、治疗率、控制率、药物控制率均低于国内10个地区人群标化率，比较差异均有统计学意义（P<0.01）；服务后，患者的高血压知晓率、药物控制率均高于国内10个地区人群标化率和服务前，且高血压治疗率、控制率均高于服务前，比较差异均有统计学意义（P<0.01）。结论：家庭医生团队式服务能够提升高血压患者的知识，转变患者的态度，提升自我管理行为，可以更有效地控制和稳定血压，值得基层社区健康服务中心推广应用。
　　【关键词】 家庭医生； 高血压病； 干预； 评价
　　Evaluation of the Effect of Family Doctor Team Service on the Intervention of Hypertensive Patients in the Community/TANG Wenhui，LU Pingtao，ZENG Yunhong.//Medical Innovation of China，2018，15（07）：136-140
　　【Abstract】 Objective：To explore the intervention effect of family doctor group service on hypertension patients in community，and to provide theoretical basis for the management mode of community hypertension patients.Method：A total of 276 patients with hypertension diagnosed by the hospital or community health service center in Guangming New District of Shenzhen from 2015 to 2016 were selected，they were received family doctor group service.The KAP survey results and blood pressure of hypertensive patients before and after one year of service were compared，the awareness rate，treatment rate，control rate and drug control rate of patients before and after service were statistically analyzed，and compared with the standardized rates of 10 regions in China.Result：After service，the knowledge of hypertension patients were better than before service （P<0.01），at the attitude of hypertension，only “exercise every day after high blood pressure” was better than that of before service （P<0.01），other attitude items were compared，the differences were not statistically significant（P>0.05），at the change of behavior，regular monitoring of blood pressure and adherence to exercise were better than those of before service（P<0.05），other change of behavior were compared，the differences were not statistically significant（P>0.05）.After service，the systolic and diastolic pressure of patients were lower than those of before service，the differences were statistically significant（P<0.01）.Before the service，the awareness rate，treatment rate，control rate and drug control rate of patients were lower than those of 10 regions in China，the differences were statistically significant（P<0.01），after service，the awareness rate and drug control rate of patients were higher than those of 10 regions in China and brfore service，and the treatment rate and control rate of patients were higher than those of before service，the difference were statistically significant（P<0.01）.Conclusion：Family doctors group service can improve the knowledge of hypertension patients，change their attitude，improve their self-management behavior，can more effectively control and stabilize blood pressure，and is worth popularizing and applying in primary community health service center.

相关热词搜索：家庭医生 干预 高血压患者 团队 评价