知己健康管理模式在区高血压管理中的应用效果研究.docxVIP

知己健康管理模式在社区高血压管理中的应用效果研究 林芳芳① 敖虎山① 刘雷② 李玉玲③ 洪秋兰④ 张大发⑤ 安秀清④ 摘要 目的 探讨知己健康管理模式对社区高血压病患者的应用效果，及其对社区慢病管理的作用。方法 选择北京市527个社区患有高血压和/或糖尿病的患者进行知己健康管理，其中高血压患者是本研究的主要研究对象。共14404例慢性病患者接受了管理（其中只患有高血压者3167例），在为期3个月的强化管理期间，实施量化运动、量化饮食、指导合理用药和健康教育。进而，评价模式应用效果和费用情况。结果 接受管理的3167例高血压患者经3个月强化管理后，高血压控制率达到70%，人均药费减少31.26元/月。一年后，高血压患者门诊医疗费用平均下降38元/月，住院人次减少64.9%，住院费用下降37.5%。患者对管理服务方式满意度为99%，对其病情及危险因素控制满意度达到98%。结论 知己健康管理对社区高血压病患者的病情控制作用明显，且有利于降低药费，管理模式受到患者欢迎。可认为，在社区慢性病管理中推行知己健康管理模式，是社区卫生服务对慢性病管理的突破点，也是促进社区卫生服务可持续发展的方法和途径。 关键词 高血压 社区 知己健康管理 效果 中图分类号 R197.3 文献标志码 B 文章编号 1001-5329 The Effect of Self-Management Health Care Mode on Patients with Hypertension Control in Community/ Lin Fang-fang, Ao Hu-shan, Liu Lei, et al. // Chinese Hospital Management, 年,卷(期):起始页-结束页 Abstract Objective To evaluate the impact of self-management health care mode on hypertension control and chronic disease manage in community. Methods Randomly select 527 communities in Beijing city undergoing self-management health care mode, communities monitored the quantitative management of motion and diet, provided health care education and guidance on rational drug use during the three-month enhanced managing period. Then, the study evaluated the effect of the mode and the medical cost. Results A total of in 8 districts of Beijing applied the self-management health care system between January 2005 and December 2009, and 1610 general practitioners (GP) received training, 14404 chronic patients were managed (including 3167 hypertension patients). After a three-month management, the ratio of hypertension control went to 60-70%, and drug cost reduced 31.26 yuan for each month per capita. One year later, the outpatient cost of hypertension patients could save 38 yuan each month per capita, the visits and costs of inpatients decreased by 64.9% and 37.5%. The management mode satisfaction in patients was 99%; the satisfaction of disease control and risk factors control was up to 98%. Conclusion Self-management health care mode wa