高血压社区疾病管理计划应用研究.docVIP

高血压社区疾病管理计划应用研究 　　［摘 要］ 目的 探讨适合不同地区和人群的可持续发 展的高血压社区疾病管理模式。方法 ①分别选择城市、农村和城镇三个 社区中15岁以上常驻（居住半年以上）人群为高血压疾病管理对象。②根据《中国高血压防 治指南》制定“规模化、规范化和信息化”为核心的高血 压社区疾病管理计划。③围绕高血压的防治目标建立信息化管理网络。④每个实施阶段都设 置了相应培训内容和考核评估标准。结果 ①专业人员的高血压防治知识 水平有大幅度提高 。社区人群管理能力及自身发展能力明显提高。社区相关政策及环境有显著变化。②迅速提 高高血压“三率”、人群平均血压水平有所下降、不良生活方式及行为有所改善、急性事件 的发生较周边社区减少。③ 群众对社区卫生服务的信任、满意度增加。结论 高血压社区疾病管理计划不仅在城市社区可以有效实施，在农村实施同样也可以达到预 期的效果。 　　［关键词］ 高血压；社区；疾病管理 　　中图分类号：R544.1；R108 　　文 献标识码：A 　　文章编号：1009-816X(2007)05-030 5-04 　　The Applied Research of Disease Management Programmed for Hypertensio n in Community. TANG Xin-hua,JIN Hong-yi,XU Xiao-lin, et al.Zhejiang Hospital, Hangzhou 310013, China 　　［Abstract］ Objective The discussion suits different local and crowds sustainable development hypertension community disease manages the patt ern. Methods (1) separately chooses the city, the countryside an d in the cities three communities above 15 years old resident (lives above for h alf year) the crowd to manage the object for the hypertension disease. (2) “Prevents and controls Guide accor ding to the Chinese Hypertension” to formulate “the scale, the standardization an d the information” manages the plan for the core hypertension community disease .(3) Revolves the hypertension the preventing and controlling goal establishment information management network. (4) Each implementation stage has all establish ed the corresponding training content and the inspection appraisal standard. Results (1) Specialists hypertension prevents and controls the sta te-of-art to ha ve the large scale enhancement. Community crowd management ability and own devel opment ability distinct enhancement. Community correlation policy and environmen t change. (2) Rapidly enhances the hypertension “three rate”, the crowd averag eblood pressure level has the drop, not the good life style and the behavior has the improvement, the acute event occurrence comparatively peripheral community r educes. (3) Populace to community health service trust, de