| [Objective]Taking the Internet + medical service as an opportunity,relying on the"Hospital-Community-Family" ternary linkage hypertension platform of Nanjing Traditional Chinese Medicine Hospital,based on the multidisciplinary team management of medical information engineers,and combining with the operation of family physicians to carry out the information management mode of hypertension.Focusing on blood pressure monitoring,strengthen patient lifestyle interventions and medication management.To explore the influence of"Hospital-Community-Family" ternary linkage hypertension platform management mode based on Internet+ on the average blood pressure drop,blood pressure control rate,compliance rate,community chluonic disease management effect and experience of hypertension patients,in order to provide reference for the management mode of hypertension chronic disease.[Methods]1.To establish a multidisciplinary management team:cooperated by the medical-pharmaceutical-nursing team and the information department.The team members include 2 cardiovascular doctors from Nanjing Traditional Chinese Medicine Hospital,1 specialist nurse,1 pharmacist,and 1 information engineer.There are 2 doctors and nurses from Shuangtang Community Health Service Center and Daishan Community Health Service Center,and 1 master graduate student in nursing specialty.All team management members receive training in ternary linkages and network intervention methods and skills.2.Based on the Internet + to carry out "Hospital-Community-Family"Trinity Hypertension Management:Select 396 hypertensive patients who have accepted community archive management from February 2018 to June 2018 in Nanjing Traditional Chinese Medicine Hospital,Shuangtang Community Health Service Center and Daishan Community Health Service Center.According to the principle of stratified randomization,hypertensive patients who met the inclusion criterias were randomly divided into control group(n=198)and intervention group(n=198).There were no significant differences in the general data of age,sex,disease duration,marital status,family history,related complications,education level,smoking and drinking(P>0.05).The control group received a community-led conventional chronic disease management model.The intervention group received the "Hospital-Community-Family" trinity hypertension management,The blood pressure was assessed before the intervention,three months and six months after the intervention.The implementation rate of patients'compliance behavior,TCM syndrome score,the utilization of health resources and the effect of community chronic disease management were evaluated in six months after the intervention.[Results](1)Blood pressure:The results show that both the systolic and diastolic blood pressures of the two groups decreased during the entire intervention period,At the 3 months,there were no statistical significance differences in systolic and diastolic blood pressure between the two groups(P = 0.414,P = 0.953),With the extension of the intervention period,the systolic and diastolic blood pressures of the intervention group were significantly lower than those of the control group at 6 months(P=0.001,P=0.006).In terms of the drop in blood pressure,The intervention group decreased systolic blood pressure by 3.2mmHg and diastolic blood pressure by 1.25mmHg more than the control group.The results showed that systolic blood pressure decreased by 5.38 mmHg(95%CI:4.200-6.696)and diastolic blood pressure decreased by 3.10 mmHg(95%CI:2.246-4.058)in the control group after 3 months of community-led conventional hypertension management.The intervention group decreased systolic blood pressure by 3.2mmHg and diastolic blood pressure by 1.25mmHg more than the control group at 3months;and the systolic pressure and diastolic pressure decreased by 6.49 mmHg and 3.12 mmHg more in the intervention group than in the control group(P<0.05)at 6 months.After intervention,the control rate of blood pressure in the intervention group was significantly higher than that in the control group(P=0.001).(2)Execution rate of compliance behavior:After 6 months,there was no significant difference between the two groups in terms of medication rates and smoking cessation rates(P=0.110,P=0.167);salt intake control rate of the intervention group,oil intake control rate,regular exercise rate and alcohol restriction rate were higher than the control group,and the difference was statistically significant(P<0.05).(3)TCM clinical syndrome scores:After 6 months,the TCM syndrome scores of the control group decreased by 2.00±2.97 points,with an average score of 11.1 7±4.70.The intervention group decreased by 4.12±4.01 compared with pre-intervention,with an average score of 8.5±.3.90;The difference of TCM syndrome scores between the two groups after intervention was statistically significant(P=0.001);(4)The utilization of health services:Within 6 months,the average number of re-admissions in the control group was 0.06±0.26,and the intervention group was 0.04±0.20.There was no difference in the difference between the two groups(P=0.396);the average number of outpatient visits was 2.50±1.50 in the control group and 2.26±1.32 in the intervention group.There was no statistical difference between the two groups(P=0.102)(5)The Patient Assessment of Chronic Illness Care:The total score of PACIC in 191 patients in the control group was 2.8510.47.which has a certain gap from the score of 5.and the evaluation result was "general".indicating the perceived level of community chronic disease management behavior was more general;the total score of PACIC in the 189 patients in the intervention group was 4.32±0.26,and the evaluation result was "very satisfactory".The total score of the intervention group and the median of each dimension were higher than the control group[Conclusions]The research results show that the use of "Hospital-Community-Family" trinity hypertension management mode can improve patients' blood pressure control rate,improve the compliance rate of compliance behavior,reduce TCM syndrome scores,reducing the use of health services in patients with chronic diseases,Improving the satisfaction of community chronic disease management. |
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