目的 评价分级管理模式在社区高血压规范化管理中的效果,探索规范、有效的社区高血压防治模式.方法 2009年1月～2011年1月在北京市大兴区庞各庄镇西高社区随机抽取高血压患者150例,按高血压危险分层进行分级管理2年,设立个人健康电子档案,对血压、生活方式、心血管危险因素控制情况进行随访.结果 对150例高血压患者实施分级管理2年后,该群体高血压治疗率由62.67%提升至88.03%,控制率由31.33%提升至61.27%,分别增加25.36%、29.94%,差异有显著统计学意义(P＜0.01);1、2、3级管理组收缩压(SBP)较基线水平分别下降5.2 mmHg、14.3 mmHg、18.4mmHg;舒张压(DBP)较基线水平分别下降1.9 mmHg、9.1 mmHg、10.3 mmHg,且管理级别愈高,血压下降数值愈大;高盐饮食、肥胖、饮酒及缺乏运动比例分别下降66.44%、30.84%、30.03%、36.25%,高血压主要患病危险因素得到了良好控制;同时一些主要可逆心血管危险因素,如吸烟、血糖及血脂异常比例分别下降31.06%、14.73%、16.20%,也得到了有效控制.结论 本研究发现:(1)通过定期开展社区健康教育提高患者对高血压健康知识的认知水平和自我管理意识,同时由社区专职医师提供定期专业治疗指导和建议及患者家属负责院外监督治疗,形成有效的社区高血压患者治疗监管机制,从而提高患者对长期治疗的依从性,同时保证治疗方案的规范性,能够明显提高社区高血压患者的治疗率和控制率;(2)根据患者个体心血管风险水平分层,进行社区高血压分级管理,进行个体化治疗和管理,在有效管理血压水平的同时,患者并存的可逆心血管危险因素也得到了有效的控制,降低了心血管总体危险.%Objective Aimed to evaluate the effect of classification management mode in community-based hypertension manegement. Methods From January 2009 to January 2011, 150 essential hypertensive patients were randomly collected in Xigao Community, Panggezhuang Town, Daxing District, Peking. 2-year-classification management was carried out among the patients according to cardiovascular risk stratification. We also set personal electronic health records to follow-up for 2 yeas, including blood pressure, lifestyle, reversible cardiovascular risk factor. Results After implementation of classification management in 150 cases hypertensive patients for 2 years, the treatment rate and the control rate was significantly improved, As compared to the baseline level, Blood pressure (SBP/DBP) significantly decreased in 1st, 2nd and 3rd level management group respectively, and the higher the management level, the greater the value of blood pressure dropped. The proportion of high salt diet, obesity, alcohol consumption and lack of exercise significantly dropped respectively. At the same time some major reversible cardiovascular risk factors proportion dropped respectively, have also been effectively controlled. Conclusion By regular community health education, can improve essential hypertension health knowledge level and self management consciousness in hypertensive patients. At the same time the regular professional treatment guidelines and recommendations provided by physicians and the out-hospital supervision on treatment by family members, can improve the patients' compliance with long-term treatment, and can also improve the treatment rate and control rate in hypertensive patients. By the implementation of classification management according to cardiovascular risk stratification, blood pressure levels and the reversible cardiovascular risk factors can be effectively managed and controlled, then reduce the overall cardiovascular risk.
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