| 1、BackgroundHypertension is the most common chronic diseases, and it is seriously harmful to human health. Hypertension has become a major public health problem worldwide. Currently about 25%-35%of adults in the world suffer from hypertension, and about 60%-70% people over 70-year-old suffer from hypertension. The number of adults over 18-year-old in Shanghai who suffer from hypertension has reached 23.6% in 2008, and there are about 3 million hypertension patients in Shanghai. The prevalence of hypertension is very serious, and it is important to take effective interventions to control high blood pressure.In 2004, Shanghai established the hypertension-controlling strategy which names hierarchic classification management and it is consisted of carrying out health education to the general population, taking interventions to control the risk factors for high-risk groups and carrying out standardized management of the disease groups. In order to meet the higher requirements of the prevention and treatment, Shanghai CDC set up detailed-management for the patients with hypertension which is based on the hierarchical classification management and selected some communities to do this pilot project. Tianping Community is one of the community of them.2、ObjectiveTo analyze the implementation process of detailed- management for the patients with hypertension, evaluate the effect of detailed-management, summed up the experiences and shortcomings of detailed-management and to provide basis for the future implementation of community-based management of hypertension.3、MethodsThe quantitative data is collected from the management records and questionnaires of 197 hypertension patients who receive a whole time detailed-management. The data is analyzed by SPSS16.The qualitative data is collected from policy documents and the qualitative interviews of the medical staffs who take part in the detailed-management and hypertension patients who receive a whole time detailed-management. The qualitative data is analyzed by the method of summarizing and classification.4、Results4.1 Changes in some hypertension-related indicators of the patient before and after the implementation of detailed- management for the patients with hypertension: After 1-year implementation of detailed- management for the patients with hypertension, there are further improvement in the awareness rate, treatment rate and control rate of the patients. Awareness rates of hypertension improve from 98% to 99.5%, treatment rate of improve from 93.9% to 98.5%, control rate improve from 25.4% to 95.4%. After the intervention, the patient’s healthy attitude changes obviously, but the health behavior of patients don’t have significant improvement.4.2 The implementation process of detailed-management and the difficulties:4.2.1 In order to ensure the implementation of detailed-management, they first set up a special leading group for detailed-management in Tianping Community. In the group, there is a explicit division of responsibility and the responsibility arrives a person, At the same time, they established a detailed-management team which responsible for the implementation of detailed-management for the patients with hypertension.4.2.2 Because the detailed-management is a part-time job for the medical staff, and they have lot of works already, it is difficult for them to efficient implement the detailed- management.4.2.3 5,000 yuan conventional funding can hardly meet the needs of the implementation of the work.4.2.4 The existing training is difficult to meet the training needs of medical personnel.4.2.5 During the medical staffs follow-up the patients, they give personalized intervention suggestions to patients according to their condition. There are difficulties for medical staffs to complete the "management record of the patient".4.2.6 During the implementation of detailed-management, there are various activities for patients. The participation rates of the hypertension patient increased, but the satisfaction rates do not increase.4.2.7 The information system for detailed-management is primarily used to upload the patients’information for the health management commissioner, and the team medical staffs’utilization rate of the information system is not high.4.2.8 The family support system and elderly care project don’t carry out.5、Conclusion5.1 The detailed-management is more comprehensive than the hierarchical classification management.5.2 The effect of the detailed-management has appeared, but the patients’health behaviors needs to be further improved5.3 There are many difficulties to implement the detailed-management, and the policies of the detailed-management need to be further implement5.3.1 Because it is inadequate in human resources and funding, the implementation of detailed- management is quite difficult.5.3.2 The training need is huge, and it needs some support to the medical staffs’ training.5.3.3 The "management record of the patient" is too complicated5.3.4 The utilization of information system is not high, and the module in the system needs to be improved.6、Suggestion6.1 To strengthen the support of detailed- management6.2 To strengthen collaboration of the three networks6.3 To expand the training range, further training content6.4 To improve the operability of "management records of the patient"6.5 To further promote the information system platform and increase the utilization of the system... |
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