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目的:探讨大医院技术支援社区卫生服务站的模式,同时为制订有效的社区高血压健康管理模式提供依据。方法:小榄医院成立慢性病管理专家组,对管辖的6家社区卫生服务站实行“一对一”派对帮扶,以管辖的6个社区退休老人(男60岁或以上、女55岁或以上)健康筛查出的1943例高血压患者为对象进行分级健康管理,比较管理前后规范管理率、血压控制率、健康教育干预效果。结果:实行医院专家驻站帮扶管理后,社区高血压规范管理率由58.2%提高到98%(P<0.01),血压控制率由23.8%提高到67.6%(P<0.01),相关知识知晓率由42.3%提高到85.8%(P<0.01),服药依从性由56.6%提高85.2%(P<0.01),有不良行为如吸烟、过量饮酒、嗜盐、不合理膳食、缺乏运动的患者比例下降(P<0.05),基本达到高血压社区规范管理效果。结论:医院专家驻站结对指导社区卫生服务站实施高血压社区规范化管理,对提高高血压患者的血压控制率是一种有效的管理模式。
Objective: To explore the mode of technical support for community health service stations in large hospitals and to provide basis for formulating an effective community health management model of hypertension. Methods: The Siu Lam Hospital set up an expert group on chronic disease management and implemented “one to one” party support to 6 community health service stations under its jurisdiction to retired seniors (male aged 60 or over and female aged 55 Or more) 1943 cases of hypertensive patients screened out healthy for grading health management, standardized management rate before and after management, blood pressure control, health education intervention effect. Results: After administration of hospital experts, the standard management rate of community hypertension increased from 58.2% to 98% (P <0.01) and the rate of blood pressure control increased from 23.8% to 67.6% (P <0.01) (P <0.01), medication adherence increased from 56.6% to 85.2% (P <0.01), and the proportion of patients with adverse behaviors such as smoking, excessive drinking, halophilic, unreasonable diet and lack of exercise increased from 42.3% to 85.8% Decreased (P <0.05), and basically reached the standard management effect of hypertensive community. Conclusion: Hospital experts stationed in pairs to guide the community health service station to implement standardized management of hypertension community, which is an effective management mode to improve blood pressure control rate in patients with hypertension.