摘要
目的评价以互联网+医生为中心的慢病管理模式在社区高血压患者管理中的应用效果。方法以2017年1月-2018年1月湘潭市各社区卫生服务中心收治的100例原发性高血压患者为观察组,以同期湘潭市中心医院普通门诊诊治的100例原发性高血压患者为对照组,观察组患者接受以互联网+医生为中心的慢病管理模式进行干预,对照组患者接受常规慢病管理模式进行干预。从监测依从性、服药依从性、自我管理能力、社会支持等层次进行干预评估,记录患者通过信息平台与医务人员进行的咨询,形成健全的健康档案系统,随访12个月。效果评价指标包括血压管理效果、健康行为干预效果、项目满意度及疾病负担指标。结果观察组的收缩压、舒张压、就诊时间、支付费用、日饮酒量、日吸烟量较基线期均明显降低(P<0.05),运动次数、运动时间、服药依从性评分、满意度较基线期均明显增高(P<0.05)。对照组的支付费用、日饮酒量、日吸烟量较基线期均明显降低(P<0.05),服药依从性评分、满意度较基线期均明显增高(P<0.05)。结局中,观察组的收缩压、舒张压、就诊时间、支付费用均明显低于对照组(P<0.05),运动次数、运动时间、服药依从性评分、满意度均明显高于对照组(P<0.05)。观察组血压达标情况和BMI正常比例均高于对照组(P<0.05)。结论以互联网+医生为中心的慢病管理模式可以辅助社区医务人员有效地做好高血压患者的疾病管理,有效提升患者的健康生活方式依从性与血压知晓率和管理率,辅助患者有效减少疾病负担,提升生活质量。
Objective To evaluate the application effect of internet+doctor-centered chronic disease management mode in the management of patients with hypertension in community.Methods 100 patients with essential hypertension admitted to community health service centers in Xiangtan from January 2017 to January 2018 were selected as the observation group,a total of 100 patients with essential hypertension who were treated in the general outpatient department of Xiangtan Central Hospital in the same period were selected as the control group.Patients received intervention with internet+doctor-centered chronic disease management mode in the observation group,while patients received intervention with conventional chronic disease management mode in the control group.Intervention evaluation was carried out at the levels of monitoring compliance,medication compliance,self-management ability and social support,and patient consultation with medical staff through the information platform was recorded to form a sound health archive system.Follow-up was conducted for 12 months.Effect evaluation indexes include blood pressure management effect,health behavior intervention effect,project satisfaction and disease burden index.Results Compared to baseline period,the systolic blood pressure,diastolic blood pressure,time of visit,payment cost,daily alcohol consumption,daily smoking of observation group were significantly reduced(P<0.05).The exercise times,exercise duration,medication adherence score,satisfaction of observation group were significantly increased(P<0.05).The payment cost,daily alcohol consumption,daily smoking of control group were significantly reduced(P<0.05).The medication adherence score,satisfaction of control group were significantly increase(P<0.05).The systolic blood pressure,diastolic blood pressure,time of visit,payment cost of observation group were significantly lower than those of control group(P<0.05).The exercise times,exercise duration,medication adherence score,satisfaction of observation group were significantly higher than that of control group(P<0.05).Blood pressure and BMI of the observation group were higher than those of the control group(P<0.05).Conclusion The internet+doctor-centered chronic disease management mode is able to effectively support health management in patients with hypertension in the community.At the same time,the equipment can improve healthy lifestyle compliance and awareness or self-management of blood pressure.In this manner,the burden of disease is reduced and the quality of life is improved.
作者
刘政
王锡榜
周艳红
符桑
冯雷雨
赵旅
LIU Zheng;WANG Xibang;ZHOU Yanhong;FU Sang;FENG Leiyu;ZHAO LYU(Department of General Medicine,Xiangtan Central Hospital,Xiangtan 411100)
出处
《解放军医院管理杂志》
2020年第2期156-161,共6页
Hospital Administration Journal of Chinese People's Liberation Army
基金
2017年湘潭市科技局重点项目支持课题(SF-YB20171005)。
关键词
慢病管理模式
互联网+医生
健康管理
社区
高血压
chronic disease management mode
internet+doctor
health management
community
high blood pressure
