【摘要】 目的：探討家庭醫(yī)生團(tuán)隊(duì)式服務(wù)對(duì)社區(qū)高血壓患者的干預(yù)效果，為社區(qū)高血壓患者管理模式提供理論依據(jù)。方法：選取2015-2016年度深圳市光明新區(qū)經(jīng)醫(yī)院或社區(qū)健康服務(wù)中心確診的高血壓患者276例，患者均接受家庭醫(yī)生團(tuán)隊(duì)式服務(wù)。比較患者接受服務(wù)前和服務(wù)滿1年后的高血壓KAP調(diào)查結(jié)果、血壓（收縮壓、舒張壓），統(tǒng)計(jì)分析患者服務(wù)前后的高血壓知曉率、治療率、控制率、藥物控制率并與國(guó)內(nèi)10個(gè)地區(qū)人群標(biāo)化率進(jìn)行比較。結(jié)果：服務(wù)后，患者高血壓知識(shí)掌握方面均優(yōu)于服務(wù)前（P<0.01）；看待高血壓的態(tài)度方面，僅“患高血壓后應(yīng)每天堅(jiān)持適量運(yùn)動(dòng)”優(yōu)于服務(wù)前（P<0.01），其他態(tài)度項(xiàng)目比較均無統(tǒng)計(jì)學(xué)意義（P>0.05）；從行為轉(zhuǎn)變方面，定期監(jiān)測(cè)血壓和堅(jiān)持運(yùn)動(dòng)方面均優(yōu)于服務(wù)前（P<0.05），其他行為轉(zhuǎn)變項(xiàng)目比較均無統(tǒng)計(jì)學(xué)意義（P>0.05）。服務(wù)后，患者收縮壓、舒張壓均較服務(wù)前降低，比較差異均有統(tǒng)計(jì)學(xué)意義（P<0.01）。服務(wù)前，患者的知曉率、治療率、控制率、藥物控制率均低于國(guó)內(nèi)10個(gè)地區(qū)人群標(biāo)化率，比較差異均有統(tǒng)計(jì)學(xué)意義（P<0.01）；服務(wù)后，患者的高血壓知曉率、藥物控制率均高于國(guó)內(nèi)10個(gè)地區(qū)人群標(biāo)化率和服務(wù)前，且高血壓治療率、控制率均高于服務(wù)前，比較差異均有統(tǒng)計(jì)學(xué)意義（P<0.01）。結(jié)論：家庭醫(yī)生團(tuán)隊(duì)式服務(wù)能夠提升高血壓患者的知識(shí)，轉(zhuǎn)變患者的態(tài)度，提升自我管理行為，可以更有效地控制和穩(wěn)定血壓，值得基層社區(qū)健康服務(wù)中心推廣應(yīng)用。
　　【關(guān)鍵詞】 家庭醫(yī)生； 高血壓��； 干預(yù)； 評(píng)價(jià)
　　Evaluation of the Effect of Family Doctor Team Service on the Intervention of Hypertensive Patients in the Community/TANG Wenhui，LU Pingtao，ZENG Yunhong.//Medical Innovation of China，2018，15（07）：136-140
　　【Abstract】 Objective：To explore the intervention effect of family doctor group service on hypertension patients in community，and to provide theoretical basis for the management mode of community hypertension patients.Method：A total of 276 patients with hypertension diagnosed by the hospital or community health service center in Guangming New District of Shenzhen from 2015 to 2016 were selected，they were received family doctor group service.The KAP survey results and blood pressure of hypertensive patients before and after one year of service were compared，the awareness rate，treatment rate，control rate and drug control rate of patients before and after service were statistically analyzed，and compared with the standardized rates of 10 regions in China.Result：After service，the knowledge of hypertension patients were better than before service （P<0.01），at the attitude of hypertension，only “exercise every day after high blood pressure” was better than that of before service （P<0.01），other attitude items were compared，the differences were not statistically significant（P>0.05），at the change of behavior，regular monitoring of blood pressure and adherence to exercise were better than those of before service（P<0.05），other change of behavior were compared，the differences were not statistically significant（P>0.05）.After service，the systolic and diastolic pressure of patients were lower than those of before service，the differences were statistically significant（P<0.01）.Before the service，the awareness rate，treatment rate，control rate and drug control rate of patients were lower than those of 10 regions in China，the differences were statistically significant（P<0.01），after service，the awareness rate and drug control rate of patients were higher than those of 10 regions in China and brfore service，and the treatment rate and control rate of patients were higher than those of before service，the difference were statistically significant（P<0.01）.Conclusion：Family doctors group service can improve the knowledge of hypertension patients，change their attitude，improve their self-management behavior，can more effectively control and stabilize blood pressure，and is worth popularizing and applying in primary community health service center.

相關(guān)熱詞搜索：家庭醫(yī)生 干預(yù) 高血壓患者 團(tuán)隊(duì) 評(píng)價(jià)