目的 评价全科医生签约服务对社区原发性高血压病患者就医行为的影响及其管理效果.方法 采用干预前后自身对照设计.选取2012年12月—2015年12月与北京西城区德胜社区卫生服务中心(以下简称中心)门诊8个全科医生团队签订《家庭医生式服务协议》,并且在中心接受8个月契约式全科医生团队健康管理的原发性高血压病患者282例.比较干预前后原发性高血压病患者血压控制率、原发性高血压病合并糖尿病患者血糖控制率、原发性高血压病合并动脉粥样硬化性心血管疾病(ASCVD)或糖尿病患者及原发性高血压病患者存在1项其他危险因素的低密度脂蛋白胆固醇(LDL-C)控制率,同时收集干预前后8个月内签约患者二级及以上医院就诊次数(包括门急诊和住院)、中心门急诊就诊次数.结果 干预后原发性高血压病患者血压控制率、原发性高血压病合并糖尿病患者血糖控制率均高于干预前(P<0.05).干预后原发性高血压病合并1项其他危险因素患者LDL-C控制率高于干预前(P<0.05).签约后8个月内较签约前8个月内患者二级及以上医院就诊次数(包括门急诊和住院)减少(P<0.01),中心门急诊就诊次数增加(P<0.01).282例研究对象,研究期间共随访2442例次,其中1954例次随访病情平稳,治疗方案不变;488例次出现显著生活方式调整或药物调整,原因529个、109类,原发性高血压病相关病情变化前5位是:白大衣高血压、硫酸氢氯吡格雷的应用、阿司匹林的应用、超声心动异常、蛋白尿.代谢异常前3位是:糖调节受损、高尿酸血症、高同型半胱氨酸血症.488例次病情变化中出现44种疾病,与血压相关前5位是:血脂异常、颈动脉硬化性疾病、高同型半胱氨酸血症、慢性肾脏病、脑梗死.常见病前3位是:便秘、上呼吸道感染、骨关节病.全部研究对象中转诊至上级医院的共53例,29个原因中前3位是脑梗死、甲状腺疾病、心律失常.结论 通过开展全科医生签约服务,原发性高血压病患者的就医行为在发生改变,分级诊疗效果逐渐显现;签约患者的健康状况明显改善.%Objective To evaluate the impact of the contract service mode of the general practitioner (GP) on the health seeking behaviors of community patients with primary hypertension and its management strategy. Methods The intervention before-and-after self-control design was used in this study. Between December 2012 and December 2015, eight GPs in the center clinic signed a "Family Physician Services Agreement" as a team in Beijing Xicheng District Desheng Community Health Service Center. During the same period, 282 primary hypertension patients received contract health management service from the team. The following indicators including blood pressure control rate of patients with primary hypertension, blood glucose control rate in patients complicated with diabetes, low-density lipoprotein cholesterol (LDL-C) control rate in patients complicated with atherosclerotic cardiovascular diseases (ASCVD) or diabetespatientsand in patients with one other risk factor, as well as the number of visits to second-class or higher-level hospitals (including outpatient/emergency visits and hospitalization) and community hospitals or clinics before and after the intervention, were compared and analyzed. Results After the intervention, the blood pressure control rate in primary hypertension patients and the blood glucose control rate in patients complicated with diabetes were significantly higher than those before the intervention (P<0.05). LDL-C control rate in patients with one other risk factor was higher than that before the intervention (P<0.05). The average number of visits to second-class or higher-level hospitals (including outpatient/emergency visits and hospitalization) during the 8 months after the intervention significantly decreased compared with the average number of visits during the same time period before the intervention (P<0.01); while the number of visits to community hospitals/clinics significantly increased (P<0.01). A total of 2 442 follow-up visits were performed in 282 patients, of which 1 954 visits showed that patients were stable and treatment regimens remained unchanged, and significant lifestyle changes or drug adjustment which were associated with 529 reasons (109 classes) were found in 488 visits. The first five hypertension-associated conditions that changed during follow-up were white coat hypertension, the use of clopidogrel hydrogen sulfate, the use of aspirin, abnormal echocardiography and proteinuria. The first three metabolic abnormalities were impaired glucose regulation, hyperuricemia and hyperhomocysteinemia. The 488 condition changes also included 44 diseases; the first five hypertension-associated diseases were dyslipidemia, carotid atherosclerosis, hyperhomocysteinemia, chronic kidney diseases and cerebral infarction. The first three common diseases were constipation, upper respiratory tract infection and osteoarthritis. Fifty-three patients were transferred to higher-level hospitals due to 29 reasons and the first three reasons were cerebral infarction, thyroid diseases and arrhythmia. Conclusion Contract service mode of the GP significantly changed the health seeking behaviors of patients with primary hypertension and improved the efficiency of the hierarchical medical system. The health status of contracted patients was also significantly improved.
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