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目的通过对辖区内健康体检中确诊的高血压病患者建档管理,对其进行全面干预,以提高高血压病的治愈率、达标率,降低高血压病的致残率、死亡率。方法对2002年辖区内40岁以上居民健康体检中确诊的高血压病患者建档管理,进行健康教育、危险因素评估与干预,合理的个体化药物治疗,保护靶器官,定期监测评价。结果辖区内高血压病血压控制达标率由2002年的6.3%提高到2008年的34.2%,高血压合并脑血管病死亡率由9.88%下降到1.15%,差异具有统计学意义(P﹤0.05)。结论通过对高血压病社区管理提高了高血压病控制率,降低了高血压病患者的致残率和死亡率。
Objective To establish a comprehensive management system of hypertensive patients diagnosed by physical examination in the area and improve the cure rate and compliance rate of hypertensive diseases and reduce the morbidity and mortality of hypertensive diseases. Methods To document and manage the hypertensive patients diagnosed in the health examination of residents above 40 years of age in 2002 area, to carry out health education, assessment and intervention of risk factors, rational individualized drug treatment, target organ protection, regular monitoring and evaluation. Results The compliance rate of hypertension control in the area was increased from 6.3% in 2002 to 34.2% in 2008, and the mortality rate of hypertension complicated with cerebrovascular disease decreased from 9.88% to 1.15%, the difference was statistically significant (P <0.05) . Conclusions The community-based management of hypertension improves the control rate of hypertension and reduces the morbidity and mortality of hypertensive patients.