社区高血压规范化管理研究
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摘要
研究目的
通过总结浙江省杭州市下城区长庆潮鸣社区卫生服务中心在社区高血压管理上的经验,比较社区高血压规范化管理方法与传统社区高血压管理方法的差异,形成系统的、规范的、完整的社区高血压规范化管理体系,并具体的阐述社区高血压规范化管理方法的内涵、内容、方法以及考核指标,为探索适合我省省情的社区高血压管理方法积累经验。
研究方法
本研究先采用现场调查、专家讨论法进行专家咨询,研究高血压社区规范化管理方案；采用随机抽样的方法,从杭州市区中随机抽取1个中心,示范社区作为实验组,随机抽取社区作为对照组,同时选取两个社区高血压患者500人,对他们在2007年、2008年、2009年三年的规范化管理效果进行比较,实证分析高血压规范化管理的效果；并最终科学、系统的对社区高血压规范化管理技术进行归纳撰写。资料管理与录入采用EXCEL软件,数据分析采用SPSS16.0统计软件。
研究结果
1.社区高血压规范化管理的内涵：社区高血压规范化管理是指在社区高血压管理的各个环节制定健全的标准、服务规范和管理办法,完善各种规章制度,建立一套系统的科学的高血压管理模式。同时,通过在医患之间建立一套维护健康的价值理念体系,达成人性化的协作关系,让全科医生和高血压患者能够共同参与到疾病的管理和治疗中来,从而达到有效管理高血压和维护健康的目的。
2.社区高血压规范化管理的内容：①制定社区高血压管理工作制度及岗位职责。②规范高血压管理的行为,建立科学的评价、考核体系。③加强社区高血压随访信息系统的管理。④提高社区高血压管理水平,改善服务质量。
3.社区高血压规范化管理的具体方法：①建立全科服务团队。②实施网格化管理。③高血压病人的流程管理。④适时随访。⑤个性化服务。⑥特殊高血压患者的健康管理。⑦健康教育兼顾人群和个体。⑧应用信息管理技术。⑨坚持效果考核。
4.社区高血压规范化管理的考核指标：①社区高血压管理效果。②高血压患者满意度。③全科团队工作绩效。
5.一般情况：示范社区所在街道,2006年,60岁以上居民中,高血压患者人数为3092人,实际管理人数为2956人。2009年,普查高血压患者人数为10859,实际管理人数为10859人。对照社区所在街道,2006年普查高血压患者人数为8382人,实际管理人数6194人。2009年,普查高血压患者人数为9309人,实际管理人数为7577人。
6.规范化管理前后高血压管理情况：示范社区高血压病的控制率2007年为61%,2008年,达到了65%,2009年达到了65%。对照社区高血压病的控制率2007年为41.5%,2008年,达到了45.3%,2009年达到了47.1%。示范社区2007年访视率93%,2008年98%,2009年97%。对照社区的访视率2007年为73.9%,2008年77.1%,2009年81.4%。
7.规范化管理前后高血压值变化情况：样本人群中,示范社区2007年第一季度血压收缩压值中位数为140mmHg,四分位间距为21mmHg;舒张压中位数为80mmHg,四分位间距为14mmHg。对照社区第一季度血压收缩压中位数为140mmHg,四分位间距为30mmHg;舒张压中位数为80mmHg,四分位间距为15mmHg。假设检验P值均大于0.05,差异无显著性。2009年第四季度,示范社区血压收缩压中位数为135mmHg,四分位间距15 mmHg;舒张压中位数80mmHg,四分位间距17.5mmHg。对照社区收缩压中位数为140mmHg,四分位间距为20mmHg;舒张压中位数为80mmHg,四分间距为15mmHg。假设检验收缩压P值小于0.05,收缩压值差异具有显著性；舒张压P值大于0.05,差异无显著性。
8.干预前后健康教育情况的变化：示范社区2007年接受健康教育人次数为3018人,健康教育覆盖率为40.7%。慢性病俱乐部参加人数210人,参与率为29.2%。2008年接受健康教育人次数为4050人次,健康教育覆盖率为54.6%。慢性病俱乐部参加人数408,参与率为39%；2009年接受健康教育人次数为2600人次,健康教育覆盖率为35.1%。慢性病俱乐部参加人数205人,参与率为18.7%。对照社区未开展慢性病俱乐部活动,且健康教育活动由所在街道统一开展,因此对照街道2007年接受健康教育人数为640人,健康教育覆盖率为7.37%。2008年接受健康教育人数为790人,健康教育覆盖率为8.8%。2009年接受健康教育人数为1040人,健康教育覆盖率为11.2%。
9.规范化管理后各方满意度情况：示范社区的第三方患者满意度评估评分达到91分,位于全国优秀水平。全科医生总体满意度达到67.74%,比基线上升16.35%。
研究结论
通过建立全科服务团队、实施网格化管理、高血压流程管理、适时随访、个性化服务、特殊人群健康管理、健康教育兼顾人群和个体、应用信息管理技术及坚持效果评价九个规范化管理环节,可以有效提高社区高血压管理的效果。与传统的高血压社区管理方法比较,高血压规范化管理更加完善、更加系统,不仅能有效缓解日益增多的社区高血压患者,同时还能在社区全科医生较为匮乏的我国提高全科医生的工作效率,使社区高血压管理向着更加系统的方向发展。
Objectives
To summarizing the hypertension management experience of Hangzhou Changqing chaoming community health service centers, compareing the traditional community hypertension management with the community-based standardization manament, finding the difference between them, then forming one systematic.standardized and completely system for hypertension management in community. We want to described the meaning, content, methods, and assessment iducators of hypertension community-based standardization manament, to exploring an suitable way for blood pressure control in china.
Methods
In this study, we used field surveys, expert advice to discuss this program. We randomly selected one community health care center an the control group, our demonstation center as the experimental group. Each group selected 500 hypertensive patients, and compared the effects of community-based standardization manament during 2007,2008,2009. At last write this standardized management techniques scientific and systematic. Data management and input use EXCEL sofyware, data analysis using statistical software SPSS 16.0.
Results
1. The meaning of hypertension community-based standardization manament
This manament mode is want to develop service standards, various rules and regulations form every aspects, then to setablish one scientific system for commnity hypertions. Meanwhile, we also hope to establish one walue system to maintain the collaborative relationship between GP and patient, so that GPs and patients could participate in the management and treament of blood presuess control, so as to achieve an effective health goal.
2. The content of hypertension community-based standardization manament
①develop the rules and job responsibilities of hypertension management.②regulate the behavior of hypertension management.③strenth the follow-up information systems.④improve the manage effect and service quality.
3. The methdes of hypertension community-based standardization manament
①establish GPs service group.②grid management.③hypertension process management.④timely follow-up.⑤personalized service.⑥special health management of patients with hypertension.⑦both population and individual health education.⑧information management technologies.⑨adhere to the effects assessment.
4. The assessment iducators of hypertension community-based standardization manament
①hypertension management effectiveness.②hypertensive patient satisfaction.③general team performance.
5. General
model community in 2006, among the residents over 60 years, the number of hypertension patients was 3092, the actual management number is 2,956. In 2009, has 10,859 hypertensive patients, the actual number of 10,859 people,all people was managedt. Control communities in 2006 had number of 8382 patients with hypertension, the actual management number is 6194. In 2009, the numben of hypertensive patients is 9309, the number of 7577 people was managed.
6. Before and after hypertension community-based standardization manament
model community hypertension control rate is 61% in 2007,2008reached 65%, 2009 reached 65%. control community's hypertension control rate is 41.5% in 2007, 2008 reached 45.3%,47.1% reached in 2009. In 2007, the visit rate of model community was 93%,98% in 2008,97% in 2009. visit rate of control community in 2007 was 73.9%, in 2008 was77.1%, and 81.4% in 2009.
7. Blood pressure value before and after
In the first quarter of 2007 year, model community's SBP Md was 140mmHg,QR was 21 mmHg; DBP Md was 80mmHg, QR was 14mmHg. In control community, SBP Md was 140mmHg, QR was 30mmHg; DBP Md was 80mmHg, QR was 15mmHg; hypothesis test P> 0.05, the difference was no significant. In the fourth quarter of 2009 year, model community's SBP Md was 135mmHg, QR was 15mmHg; DBP Md was 80mmHg QR was 17.5mmHg. In control community, SBP Md was 140mmHg, QR was 20mmHg; DBP Md was 80mmHg, QR was 15mmHg. Hypothesis test P< 0.05, systolic blood pressure values were significant differences; diastolic blood pressure's P>0.05, the difference was no statistically significant.
8. The education situation before and after
Model community for health education in 2007 to the number of 3018, health education coverage is 40.7%. Chronic Club has 210 participants, participation rate was 29.2%. the number receiving health education was 4050 in 2008, health education coverage is 54.6%. Chronic Club had 408 people, participation rate was 39%; 2009,the number receiving health education was 2600, health education coverage is 35.1%. Chronic Club had 205 participants, participation rate was 18.7%. Control communities did not carry out club activities, and health education activities carried out by the unity of the street, so in 2007,only 640 people received health education, health education coverage is 7.37%. Number of people received health education in 2008 was 790, coverage rate was 8.8%. Number of people receiving health education in 2009 was 1040 persons, health education coverage is 11.2%.
9. The patsions satisfaction before and after
model community got the patient satisfaction score of 91 points in the third-party assessment, this points is outstanding in china. Overall satisfaction with general practitioners to 67.74%,16.35% increase over baseline.
Conclusion
Through nine standardized technology,such as the establishment of general services group, the implementation of grid management, process management, timely follow-up, personalized service, special population health management, health education, both populations and individuals, the application of information management technology and adhere to the Evaluation, building Hypertension standardized management system, can improve the effect of community management of hypertension. Compared With the traditional method of community management of hypertension, community-based standardized management of hypertension is more perfect, more systematic, not only can effectively alleviate the growing number of community patients with hypertension,also can improve work efficiency while the lack of general practitioners in China, promise the community toward a more systematic hypertension management direction.
通过总结浙江省杭州市下城区长庆潮鸣社区卫生服务中心在社区高血压管理上的经验,比较社区高血压规范化管理方法与传统社区高血压管理方法的差异,形成系统的、规范的、完整的社区高血压规范化管理体系,并具体的阐述社区高血压规范化管理方法的内涵、内容、方法以及考核指标,为探索适合我省省情的社区高血压管理方法积累经验。
研究方法
本研究先采用现场调查、专家讨论法进行专家咨询,研究高血压社区规范化管理方案；采用随机抽样的方法,从杭州市区中随机抽取1个中心,示范社区作为实验组,随机抽取社区作为对照组,同时选取两个社区高血压患者500人,对他们在2007年、2008年、2009年三年的规范化管理效果进行比较,实证分析高血压规范化管理的效果；并最终科学、系统的对社区高血压规范化管理技术进行归纳撰写。资料管理与录入采用EXCEL软件,数据分析采用SPSS16.0统计软件。
研究结果
1.社区高血压规范化管理的内涵：社区高血压规范化管理是指在社区高血压管理的各个环节制定健全的标准、服务规范和管理办法,完善各种规章制度,建立一套系统的科学的高血压管理模式。同时,通过在医患之间建立一套维护健康的价值理念体系,达成人性化的协作关系,让全科医生和高血压患者能够共同参与到疾病的管理和治疗中来,从而达到有效管理高血压和维护健康的目的。
2.社区高血压规范化管理的内容：①制定社区高血压管理工作制度及岗位职责。②规范高血压管理的行为,建立科学的评价、考核体系。③加强社区高血压随访信息系统的管理。④提高社区高血压管理水平,改善服务质量。
3.社区高血压规范化管理的具体方法：①建立全科服务团队。②实施网格化管理。③高血压病人的流程管理。④适时随访。⑤个性化服务。⑥特殊高血压患者的健康管理。⑦健康教育兼顾人群和个体。⑧应用信息管理技术。⑨坚持效果考核。
4.社区高血压规范化管理的考核指标：①社区高血压管理效果。②高血压患者满意度。③全科团队工作绩效。
5.一般情况：示范社区所在街道,2006年,60岁以上居民中,高血压患者人数为3092人,实际管理人数为2956人。2009年,普查高血压患者人数为10859,实际管理人数为10859人。对照社区所在街道,2006年普查高血压患者人数为8382人,实际管理人数6194人。2009年,普查高血压患者人数为9309人,实际管理人数为7577人。
6.规范化管理前后高血压管理情况：示范社区高血压病的控制率2007年为61%,2008年,达到了65%,2009年达到了65%。对照社区高血压病的控制率2007年为41.5%,2008年,达到了45.3%,2009年达到了47.1%。示范社区2007年访视率93%,2008年98%,2009年97%。对照社区的访视率2007年为73.9%,2008年77.1%,2009年81.4%。
7.规范化管理前后高血压值变化情况：样本人群中,示范社区2007年第一季度血压收缩压值中位数为140mmHg,四分位间距为21mmHg;舒张压中位数为80mmHg,四分位间距为14mmHg。对照社区第一季度血压收缩压中位数为140mmHg,四分位间距为30mmHg;舒张压中位数为80mmHg,四分位间距为15mmHg。假设检验P值均大于0.05,差异无显著性。2009年第四季度,示范社区血压收缩压中位数为135mmHg,四分位间距15 mmHg;舒张压中位数80mmHg,四分位间距17.5mmHg。对照社区收缩压中位数为140mmHg,四分位间距为20mmHg;舒张压中位数为80mmHg,四分间距为15mmHg。假设检验收缩压P值小于0.05,收缩压值差异具有显著性；舒张压P值大于0.05,差异无显著性。
8.干预前后健康教育情况的变化：示范社区2007年接受健康教育人次数为3018人,健康教育覆盖率为40.7%。慢性病俱乐部参加人数210人,参与率为29.2%。2008年接受健康教育人次数为4050人次,健康教育覆盖率为54.6%。慢性病俱乐部参加人数408,参与率为39%；2009年接受健康教育人次数为2600人次,健康教育覆盖率为35.1%。慢性病俱乐部参加人数205人,参与率为18.7%。对照社区未开展慢性病俱乐部活动,且健康教育活动由所在街道统一开展,因此对照街道2007年接受健康教育人数为640人,健康教育覆盖率为7.37%。2008年接受健康教育人数为790人,健康教育覆盖率为8.8%。2009年接受健康教育人数为1040人,健康教育覆盖率为11.2%。
9.规范化管理后各方满意度情况：示范社区的第三方患者满意度评估评分达到91分,位于全国优秀水平。全科医生总体满意度达到67.74%,比基线上升16.35%。
研究结论
通过建立全科服务团队、实施网格化管理、高血压流程管理、适时随访、个性化服务、特殊人群健康管理、健康教育兼顾人群和个体、应用信息管理技术及坚持效果评价九个规范化管理环节,可以有效提高社区高血压管理的效果。与传统的高血压社区管理方法比较,高血压规范化管理更加完善、更加系统,不仅能有效缓解日益增多的社区高血压患者,同时还能在社区全科医生较为匮乏的我国提高全科医生的工作效率,使社区高血压管理向着更加系统的方向发展。
Objectives
To summarizing the hypertension management experience of Hangzhou Changqing chaoming community health service centers, compareing the traditional community hypertension management with the community-based standardization manament, finding the difference between them, then forming one systematic.standardized and completely system for hypertension management in community. We want to described the meaning, content, methods, and assessment iducators of hypertension community-based standardization manament, to exploring an suitable way for blood pressure control in china.
Methods
In this study, we used field surveys, expert advice to discuss this program. We randomly selected one community health care center an the control group, our demonstation center as the experimental group. Each group selected 500 hypertensive patients, and compared the effects of community-based standardization manament during 2007,2008,2009. At last write this standardized management techniques scientific and systematic. Data management and input use EXCEL sofyware, data analysis using statistical software SPSS 16.0.
Results
1. The meaning of hypertension community-based standardization manament
This manament mode is want to develop service standards, various rules and regulations form every aspects, then to setablish one scientific system for commnity hypertions. Meanwhile, we also hope to establish one walue system to maintain the collaborative relationship between GP and patient, so that GPs and patients could participate in the management and treament of blood presuess control, so as to achieve an effective health goal.
2. The content of hypertension community-based standardization manament
①develop the rules and job responsibilities of hypertension management.②regulate the behavior of hypertension management.③strenth the follow-up information systems.④improve the manage effect and service quality.
3. The methdes of hypertension community-based standardization manament
①establish GPs service group.②grid management.③hypertension process management.④timely follow-up.⑤personalized service.⑥special health management of patients with hypertension.⑦both population and individual health education.⑧information management technologies.⑨adhere to the effects assessment.
4. The assessment iducators of hypertension community-based standardization manament
①hypertension management effectiveness.②hypertensive patient satisfaction.③general team performance.
5. General
model community in 2006, among the residents over 60 years, the number of hypertension patients was 3092, the actual management number is 2,956. In 2009, has 10,859 hypertensive patients, the actual number of 10,859 people,all people was managedt. Control communities in 2006 had number of 8382 patients with hypertension, the actual management number is 6194. In 2009, the numben of hypertensive patients is 9309, the number of 7577 people was managed.
6. Before and after hypertension community-based standardization manament
model community hypertension control rate is 61% in 2007,2008reached 65%, 2009 reached 65%. control community's hypertension control rate is 41.5% in 2007, 2008 reached 45.3%,47.1% reached in 2009. In 2007, the visit rate of model community was 93%,98% in 2008,97% in 2009. visit rate of control community in 2007 was 73.9%, in 2008 was77.1%, and 81.4% in 2009.
7. Blood pressure value before and after
In the first quarter of 2007 year, model community's SBP Md was 140mmHg,QR was 21 mmHg; DBP Md was 80mmHg, QR was 14mmHg. In control community, SBP Md was 140mmHg, QR was 30mmHg; DBP Md was 80mmHg, QR was 15mmHg; hypothesis test P> 0.05, the difference was no significant. In the fourth quarter of 2009 year, model community's SBP Md was 135mmHg, QR was 15mmHg; DBP Md was 80mmHg QR was 17.5mmHg. In control community, SBP Md was 140mmHg, QR was 20mmHg; DBP Md was 80mmHg, QR was 15mmHg. Hypothesis test P< 0.05, systolic blood pressure values were significant differences; diastolic blood pressure's P>0.05, the difference was no statistically significant.
8. The education situation before and after
Model community for health education in 2007 to the number of 3018, health education coverage is 40.7%. Chronic Club has 210 participants, participation rate was 29.2%. the number receiving health education was 4050 in 2008, health education coverage is 54.6%. Chronic Club had 408 people, participation rate was 39%; 2009,the number receiving health education was 2600, health education coverage is 35.1%. Chronic Club had 205 participants, participation rate was 18.7%. Control communities did not carry out club activities, and health education activities carried out by the unity of the street, so in 2007,only 640 people received health education, health education coverage is 7.37%. Number of people received health education in 2008 was 790, coverage rate was 8.8%. Number of people receiving health education in 2009 was 1040 persons, health education coverage is 11.2%.
9. The patsions satisfaction before and after
model community got the patient satisfaction score of 91 points in the third-party assessment, this points is outstanding in china. Overall satisfaction with general practitioners to 67.74%,16.35% increase over baseline.
Conclusion
Through nine standardized technology,such as the establishment of general services group, the implementation of grid management, process management, timely follow-up, personalized service, special population health management, health education, both populations and individuals, the application of information management technology and adhere to the Evaluation, building Hypertension standardized management system, can improve the effect of community management of hypertension. Compared With the traditional method of community management of hypertension, community-based standardized management of hypertension is more perfect, more systematic, not only can effectively alleviate the growing number of community patients with hypertension,also can improve work efficiency while the lack of general practitioners in China, promise the community toward a more systematic hypertension management direction.
引文
[1]沈爱宗,陈飞虎,陈礼明.高血压患者用药依从性及影响因素研究.药物流行病学杂志.2007.(02).
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