二级医院与社区健康服务中心互动式管理在社区高血压患者健康管理中的应用及效果研究

摘要

目的：探讨二级医院与社区健康服务中心（社康中心）互动式管理在社区高血压患者健康管理中的应用及效果。方法选择深圳市宝安区西乡人民医院及其所属的35家社康中心和深圳市第七人民医院及其所属的5家社康中心作为现场试点，进行为期1年（2011年12月-2012年11月）的健康管理。其中将实施与医院互动式管理的17家社康中心作为观察组，其他未实施与医院互动式管理的23家社康中心作为对照组。通过文献研究、专家咨询制定互动式管理路径，通过试点对互动式管理模式进行验证及修改。比较健康管理前后两组患者健康管理意识及依从性变化，并分析两组患者健康管理质量。结果管理前两组患者中遵医嘱用药、主动要求管理及参加自我管理小组者所占比例比较，差异均无统计学意义（ P﹥0.05）；管理后观察组患者中遵医嘱用药、主动要求管理及参加自我管理小组者所占比例高于对照组（P﹤0.05）。观察组不良行为改变率、规范管理率及血压控制率均高于对照组（P﹤0.05）。结论二级医院与社康中心互动式管理模式能有效提高社区高血压患者管理依从性及管理质量，适宜推广。%Objective To explore the application and effect of interactive management between secongery hospitals and community health service centers on health management in community hypertensive patients. Methods Xixiang People's Hospi-tal of Baoan District,Shenzhen and its presidial 35 community health service centers,the Seventh People 's Hospital of Shenzhen and its presidial 5 community health service centers were chosen as a pilot site,and carried out health management for 1 year ( from December 2011 to November 2012 ) . 17 community health service centers implemented interactive management were served as observation group,the other 23 community health service centers did not implemented interactive management as control group. Literature research and expert consulting were used to formulate a interactive management path,pilot study was used to verify the applicability of the interactive management model. The health management awareness and compliance before and after management were compared,and the quality of health management was analyzed. Results There was no significant differences of the proportions of prescribed medication,initiatively required management and acceding self-management groups between the two groups before management(P﹥0. 05);the proportions of prescribed medication,initiatively required management and ac-ceding self-management groups of observation group were higer than those of control group after management(P﹤0. 05). The change rate of bad behavior,rate of standardized management and blood pressure control rate of observation group were higher than those of control group(P﹤0. 05). Conclusion The interactive management between secongery hospitals and community health service centers can effectively improve the compliance and quality of health management in community hypertensive pa-tients,is worthy of promotion.