基于慢病管理路径的社区高血压患者管理效果评价

史威力; 王留义; 李明艳; 赵英帅; 郭蒙蒙; 王勇

doi:10.16766/j.cnki.issn.1674-4152.002729

基于慢病管理路径的社区高血压患者管理效果评价

doi: 10.16766/j.cnki.issn.1674-4152.002729

河南省人民医院/郑州大学人民医院全科医学科，河南郑州 450003

基金项目:

河南省医学科技攻关计划项目 2018020407

详细信息

通讯作者:
王勇, E-mail: 13939047780@126.com

中图分类号: R544.1 R499
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- 文章访问数: 159
- HTML全文浏览量: 34
- PDF下载量: 25
- 被引次数: 0
出版历程
- 收稿日期: 2021-04-12
- 网络出版日期: 2022-12-30

Effect evaluation of community hypertension patients' management based on chronic disease management pathway

Department of General Practice, Henan Provincial People's Hospital/People's Hospital of Zhengzhou University, Zhengzhou, Henan 450003, China

摘要

摘要: 目的评估基于慢病管理路径对社区高血压患者实施健康管理的有效性。方法选取2019年1—6月郑州市2个辖区内高血压患者160名，采用随机数表法将其分为管理组和对照组，各80名，分别接受为期1年的基于慢病管理路径的管理和社区常规管理，1年后评估患者血压控制情况、体重指数、高血压预防知识掌握情况、药物依从性以及患者对管理方案的接受度。结果最终共入组患者154例，其中管理组78例，对照组76例。管理1年后，2组患者收缩压、舒张压均显著下降(均P＜0.05)，血压达标率均得到了显著提升，管理组优于对照组(60.2% vs. 42.1%，P＜0.05)。管理组患者在危险因素和预警症状2个方面的知识掌握人数高于对照组，差异有统计学意义(P＜0.05)。2组患者在管理后药物依从性均有明显改善(t=4.463，P＜0.001；t=3.525，P=0.001)。问卷调查显示，88.5%(69/78)的入组患者表示该管理方案具有一定的实用性，94.9%(74/78)的入组患者希望继续使用此方案进行慢病的管理。结论基于慢病管理路径的综合管理可以改善社区高血压患者的血压控制率和达标率，提高其依从性，且有助于高血压患者掌握相关的预防知识。
- 慢病管理路径 /
- 高血压 /
- 社区
Abstract: Objective To evaluate the effectiveness of health management for hypertension patients in the community based on the chronic disease management pathway. Methods A total of 160 patients with hypertension in two districts of Zhengzhou City from January 2019 to June 2019 were selected and divided into management group and control group by random number table, with 80 cases in each group. They received one-year management based on chronic disease management pathway and community routine management, respectively. After one year, blood pressure control, BMI, hypertension prevention knowledge, drug compliance and patients' acceptance of the management plan were evaluated. Results A total of 154 patients were enrolled, including 78 patients in the management group and 76 patients in the control group. After one year, systolic blood pressure (SBP) and diastolic blood pressure (DBP) of the two groups were significantly decreased (all P < 0.05), and the blood pressure compliance rate was significantly improved, while the management group was better than the control group (60.2% vs. 42.1%, P < 0.05). The number of patients in the management group who mastered the knowledge of risk factors and early warning symptoms was higher than that in the control group, with a statistically significant difference (P < 0.05). The drug compliance of the two groups was significantly improved (t=4.463, P < 0.001; t=3.525, P=0.001). The questionnaire survey showed that 88.5% (69/78) of the enrolled patients said that the management scheme had certain practicability, and 94.9% (74/78) of the enrolled people hoped to continue to use the scheme for chronic disease management. Conclusion Comprehensive management based on chronic disease management pathways can improve the blood pressure control rate and compliance rate of community hypertension patients, and help hypertension patients master relevant prevention knowledge.
- Chronic disease management pathway /
- Hypertension /
- Community

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表 1 2组高血压患者基线资料比较

Table 1. Comparison of baseline data between the two groups of hypertensive patients

组别	例数	性别(例)		年龄(x±s，岁)	BMI (x±s)	SBP (x±s，mm Hg)	DBP (x±s，mm Hg)	MMAS-8 (x±s，分)	服药种类(例)
组别	例数	男性	女性	年龄(x±s，岁)	BMI (x±s)	SBP (x±s，mm Hg)	DBP (x±s，mm Hg)	MMAS-8 (x±s，分)	1种	2种	3种
管理组	78	42	36	54.0±13.6	26.1±1.9	155.5±12.3	90.7±13.0	4.8±1.4	32	20	15
对照组	76	44	32	52.8±12.1	25.9±2.5	154.3±11.4	89.8±12.6	4.9±1.2	31	18	13
统计量		0.256^a		0.563^b	0.430^b	0.624^b	0.424^b	-0.287^b	-0.665^c
P值		0.613		0.574	0.668	0.533	0.672	0.774	0.700
注：^a为χ²值，^b为t值，^c为Z值。

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表 2 2组高血压患者管理前后收缩压及舒张压比较(x±s，mm Hg)

Table 2. Comparison of Systolic and diastolic blood pressure between the two groups (x±s, mm Hg)

组别	例数	收缩压		t值	P值	舒张压		t值	P值
组别	例数	入组时	1年后	t值	P值	入组时	1年后	t值	P值
管理组	78	155.5±12.3	137.4±11.6	16.905	＜0.001	90.7±13.0	83.2±9.3	8.521	＜0.001
对照组	76	154.3±11.4	145.2±11.4	8.484	＜0.001	89.8±12.6	85.0±10.4	6.397	＜0.001
t值		0.624	-4.218			0.424	5.076
P值		0.533	＜0.001			0.672	0.024

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表 3 2组高血压患者血压下降及血压达标率比较

Table 3. Comparison of the rate of blood pressure reduction and blood pressure compliance between the two groups

组别	例数	SBP下降[M(P₂₅, P₇₅)，mm Hg]	DBP下降[M(P₂₅, P₇₅)，mm Hg]	血压达标率(%)
组别	例数	SBP下降[M(P₂₅, P₇₅)，mm Hg]	DBP下降[M(P₂₅, P₇₅)，mm Hg]	入组时	1年后
管理组	78	18(12, 24)	4(2, 12)	10.2(8/78)	60.2(47/78)
对照组	76	6(2, 14)	2(2, 8)	9.2(7/76)	42.1(32/76)
统计量		5.796^a	-2.429^a	0.048^b	5.076^b
P值		＜0.001	0.015	0.827	0.024
注：^a为Z值，^b为χ²值。

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表 4 2组高血压患者管理前后BMI比较(x±s)

Table 4. Comparison of BMI before and after management of hypertension between the two groups (x±s)

组别	例数	入组时	1年后	t值	P值
管理组	78	26.1±1.9	25.6±2.2	2.562	0.012
对照组	76	25.9±2.5	25.9±2.3	0.412	0.682
t值		0.430	-0.941
P值		0.668	0.348

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表 5 2组高血压患者高血压预防知识掌握情况比较[例(%)]

Table 5. Comparison of knowledge of hypertension prevention between the two groups [cases (%)]

组别	例数	入组时			1年后
组别	例数	危险因素	主要危害	预警症状	危险因素	主要危害	预警症状
管理组	78	38(48.7)	45(57.7)	52(66.7)	62(79.5)	66(84.6)	70(89.7)
对照组	76	36(47.4)	47(61.8)	46(60.5)	46(60.5)	63(82.9)	53(69.7)
χ²值		0.028	0.276	0.627	6.606	0.084	12.315
P值		0.876	0.600	0.428	0.010	0.772	0.001

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表 6 2组高血压患者管理前后药物依从性比较(x±s，分)

Table 6. Comparison of medication compliance of hypertension patients before and after management between the two groups (x±s, points)

组别	例数	入组时	1年后	t值	P值
管理组	78	4.83±1.45	5.26±1.40	4.463	＜0.001
对照组	76	4.89±1.18	5.21±1.15	3.525	0.001
t值		0.287	0.856
P值		0.774	0.394

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表 7 管理组患者对慢病管理路径管理的接受度评估(n=78)

Table 7. Evaluation of patients' acceptance of chronic disease management path management in the management group (n=78)

项目	例数(%)
管理方案很实用，容易实施	69(88.5)
管理方案贴近生活、随访方便	65(83.3)
管理方案很容易执行	72(92.3)
愿意帮助方案进行修正	60(76.9)
接受管理方案对我后续管理	74(94.9)

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