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: 319
- HTML全文浏览量: 62
- PDF下载量: 30
- 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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参考文献(20)

[1]	中国心血管健康与疾病报告编写组. 中国心血管健康与疾病报告2019概要[J]. 中国循环杂志, 2020, 35(9): 833-854. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGXH202009001.htm China Cardiovascular Health and Disease Report Compilation Group. Report on Cardiovascular Health and Diseases in China 2019: An Updated Summary[J]. Chinese Circulation Journal, 2020, 35(9): 833-854. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGXH202009001.htm
[2]	LU J P, LU Y, WANG X C, et al. Prevalence, awareness, treatment, and control of hypertension in China: Data from 1.7 million adults in a population-based screening study (China PEACE Million Persons Project)[J]. Lancet, 2017, 390(10112): 2549-2558. doi: 10.1016/S0140-6736(17)32478-9
[3]	罗瑶. 新形势下临床路径实施的困难及对策[J]. 中国基层医药, 2020, 27(15): 1892-1894. doi: 10.3760/cma.j.issn.1008-6706.2020.15.024 LUO Y. Study on the difficulties and countermeasures of clinical pathway implementation in the new situation[J]. Chinese Journal of Primary Medicine and Pharmacy, 2020, 27(15): 1892-1894. doi: 10.3760/cma.j.issn.1008-6706.2020.15.024
[4]	DU Z H, SUN X M. Clinical pathway for the community-level management of patients with type 2 diabetes[J]. Int J Health Plann Manage, 2019, 34(3): 975-985. doi: 10.1002/hpm.2868
[5]	SMITH A, BANVILLE D, GRUVER E J, et al. A clinical pathway for the care of critically ill patients with asthma in the community hospital setting[J]. Hosp Pediatr, 2019, 9(3): 179-185. doi: 10.1542/hpeds.2018-0197
[6]	中华医学会全科医学分会, 中华医学会《中华全科医师杂志》编辑委员会, 心血管系统疾病基层诊疗指南编写专家组. 高血压基层诊疗指南(2019年)[J]. 中华全科医师杂志, 2019, 18(4): 301-313. Chinese Medical Association, Chinese Medical Journals Publishing House, Chinese Society of General Practice, Editorial Board of Chinese Journal of General Practitioners of Chinese Medical Association, Expert Group of Guidelines for Primary Care of Cardiovascular Disease. Guideline for primary care of hypertension(2019)[J]. Chinese JOurnal of General Practitioners, 2019, 18(4): 301-313.
[7]	葛君, 汪朝晖, 宣玲. 高血压患者血清hs-CRP、Hcy及UA水平与颈动脉粥样硬化的相关性研究[J]. 中华全科医学, 2019, 17(7): 1138-1141. doi: 10.16766/j.cnki.issn.1674-4152.000884 GE J, WANG C H, XUAN L. Correlation research between serum hs-CRP, Hcy, UA and carotid atherosclerosis of patients with essential hypertension[J]. Chinese Journal of General Practice, 2019, 17(7): 1138-1141. doi: 10.16766/j.cnki.issn.1674-4152.000884
[8]	ZHAO Y, OLDENBURG B, ZHAO S Q, et al. Temporal trends and geographic disparity in hypertension care in China[J]. J Epidemiol, 2020, 30(8): 354-361. doi: 10.2188/jea.JE20190029
[9]	LIANG X H, ZHONG H Y, XIAO L. The effect of community hypertension management on blood pressure control and its determinants in southwest China[J]. Int Health, 2020, 12(3): 203-212. doi: 10.1093/inthealth/ihaa002
[10]	国家心血管病中心国家基本公共卫生服务项目基层高血压管理办公室, 国家基层高血压管理专家委员会. 国家基层高血压防治管理指南2020版[J]. 中国循环杂志, 2021, 36(3): 209-220. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGXH202103001.htm The National Essential Public Health Service Program Office for Management of Hypertension in Primary Health Care; National Center for Cardiovascular Diseases; National Committee on Hypertension Management in Primary Health Care. National Clinical Practice Guidelines on the Management of Hypertension in Primary Health Care in Chnia(2020)[J]. Chinese Circulation Journal, 2021, 36(3): 209-220. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGXH202103001.htm
[11]	GONZÁLEZ Y V, CAMPBELL N R C, BARRERA E P, et al. Implementation of a community-based hypertension control program in Matanzas, Cuba[J]. J Clin Hypertens (Greenwich), 2020, 22(2): 142-149. doi: 10.1111/jch.13814
[12]	史生铭, 汪娟, 黄耀庭, 等. 上海市某社区家庭医生签约服务现况[J]. 医药论坛杂志, 2020, 41(4): 95-97, 101. https://www.cnki.com.cn/Article/CJFDTOTAL-HYYX202004026.htm SHI S M, WANG J, HUANG Y T, et al. Current situation of contracted services of family doctors in a community in Shanghai[J]. Journal of Medical Forum, 2020, 41(4): 95-97, 101. https://www.cnki.com.cn/Article/CJFDTOTAL-HYYX202004026.htm
[13]	徐卫刚, 彭德荣, 陈晨, 等. 家庭医生团队闭环路径管理对冠心病患者的干预效果研究[J]. 中国全科医学, 2019, 22(28): 3455-3460. https://www.cnki.com.cn/Article/CJFDTOTAL-QKYX201928016.htm XU W G, PENG D R, CHEN C, et al. Interventional effect of the closed-loop management by family physicians team on patients with coronary heart disease[J]. Chinese General Practice, 2019, 22(28): 3455-3460. https://www.cnki.com.cn/Article/CJFDTOTAL-QKYX201928016.htm
[14]	高传玉. 防治心血管疾病的新策略[J]. 中华实用诊断与治疗杂志, 2017, 31(5): 417-422. https://www.cnki.com.cn/Article/CJFDTOTAL-HNZD201705001.htm GAO C Y. New strategies for cardiovascular disease prevention and treatment[J]. Journal of Chinese Practical Diagnosis and Therapy, 2017, 31(5): 417-422. https://www.cnki.com.cn/Article/CJFDTOTAL-HNZD201705001.htm
[15]	CHEN Y J, LI X X, JING G Z, et al. Health education interventions for older adults with hypertension: A systematic review and meta-analysis[J]. Public Health Nurs, 2020, 37(3): 461-469.
[16]	史菲菲, 庄兰艮, 施冠华, 等. 并发症体验式教育在低学历2型糖尿病患者中的应用效果观察[J]. 中华全科医学, 2021, 19(3): 446-448, 522. doi: 10.16766/j.cnki.issn.1674-4152.001832 SHI F F, ZHUANG L G, SHI G H, et al. Effect of experience-based education on complications in patients with type 2 diabetes mellitus with low educational background[J]. Chinese Journal of General Practice, 2021, 19(3): 446-448, 522. doi: 10.16766/j.cnki.issn.1674-4152.001832
[17]	李利华, 李莉, 魏红梅. 护理干预对健康体检中发现原发性高血压患者的依从性及血压控制效果的影响[J]. 河北医学, 2016, 22(7): 1177-1179. https://www.cnki.com.cn/Article/CJFDTOTAL-HCYX201607049.htm LI L H, LI L, WEI H M. Nursing Intervention on the Blood Pressure Control and Compliance in Patients with Primary Hypertension Discovered in a Health Examination[J]. Hebei Medicine, 2016, 22(7): 1177-1179. https://www.cnki.com.cn/Article/CJFDTOTAL-HCYX201607049.htm
[18]	汪晓月, 王学军. 微信远程评估和干预平台对乳腺癌患者化疗期间不良反应、心理状态及生命质量的影响[J]. 中华全科医学, 2020, 18(1): 94-97. doi: 10.16766/j.cnki.issn.1674-4152.001177 WANG X Y, WANG X J. Effect of WeChat-based symptom assessment and self-intervention on adverse reactions, mental state and quality of life in patients with breast cancer during chemotherapy[J]. Chinese Journal of General Practice, 2020, 18(1): 94-97. doi: 10.16766/j.cnki.issn.1674-4152.001177
[19]	卢琦, 吕婕, 孟宪静. 基于微信平台的健康教育对空腹血糖受损体检人群生活质量影响的研究[J]. 河北医学, 2017, 23(1): 141-144. https://www.cnki.com.cn/Article/CJFDTOTAL-HCYX201701047.htm LU Q, LYU J, MENG X J. Study on the influence of health education based on wechat platform on the quality of life of people undergoing physical examination with impaired fasting blood glucose[J]. Hebei Medicine, 2017, 23(1): 141-144. https://www.cnki.com.cn/Article/CJFDTOTAL-HCYX201701047.htm
[20]	李富军, 杨利娟, 黄晓鸥, 等. 社区与家庭一体化管理模式在农村地区冠心病二级预防中的探索[J]. 中华全科医学, 2019, 17(8): 1360-1362. doi: 10.16766/j.cnki.issn.1674-4152.000944 LI F J, YANG L J, HUANG X O, et al. The integration of community and family management model in rural areas in the secondary prevention of coronary heart disease[J]. Chinese Journal of General Practice, 2019, 17(8): 1360-1362. doi: 10.16766/j.cnki.issn.1674-4152.000944