全科医学管理模式下社区失能老年高血压患者管理有效性的临床研究

Clinical Study on the Effectiveness of Managing Elderly Hypertensive Patients with Disability in the Community under the General Practice Model

摘要: 目的：探讨全科医学管理模式下长期照护对社区失能老年高血压患者血压控制、抑郁水平、生活质量及心脑血管事件发生的影响，为优化失能老年人慢病管理提供依据。方法：采用随机分组方法，将200例社区失能老年高血压患者分为研究组(n = 100)和常规组(n = 100)。研究组接受全科医学管理模式下的长期照护，包括每周护士入户随访、每月全科医师入户评估、个体化药物管理、生活方式干预、康复指导及心理支持；常规组采用社区常规高血压随访管理。比较两组干预前及干预12个月后的血压水平、CES-D抑郁评分、EQ-5D生活质量指数及主要心脑血管事件发生情况。结果：① 两组基线一般资料差异无统计学意义(P > 0.05)。② 12个月干预后，研究组收缩压和舒张压显著优于常规组(均P < 0.05)。③ 研究组CES-D评分改善幅度优于常规组(P < 0.05)；研究组EQ-5D指数改善也显著优于常规组(P < 0.05)。④ 随访期间两组主要心脑血管事件发生率分别为6%和9%，差异无统计学意义(P = 0.421)，表明全科医学管理模式安全可靠。结论：全科医学管理模式能显著改善社区失能老年高血压患者的血压控制、抑郁状态及生活质量，且不增加心脑血管事件风险，安全性良好。作为“全人、连续、整合”照护的重要实践模式，全科医学管理模式适用于失能老年慢病人群，值得在社区卫生服务中推广。

Abstract: Objective: To explore the effects of long-term care under a general practice–based management model on blood pressure control, depression levels, quality of life, and the incidence of cardiovascular and cerebrovascular events in community-dwelling disabled elderly patients with hypertension, providing evidence for optimizing chronic disease management in this population. Methods: A total of 200 community-dwelling disabled elderly patients with hypertension were randomly assigned to the study group (n = 100) and the routine group (n = 100). The study group received long-term care based on a general practice management model, including weekly home visits by nurses, monthly home assessments by general practitioners, individualized medication management, lifestyle interventions, rehabilitation guidance, and psychological support. The routine group received conventional community-based hypertension follow-up management. Blood pressure levels, CES-D depression scores, EQ-5D quality of life index, and major cardiovascular and cerebrovascular events were compared between the two groups before intervention and after 12 months. Results: ① Baseline characteristics showed no significant differences between the two groups (P > 0.05). ② After 12 months of intervention, both systolic and diastolic blood pressure in the study group were significantly better than those in the routine group (both P < 0.05). ③ Improvements in CES-D scores were greater in the study group than in the routine group (P < 0.05), and the increase in EQ-5D index was also significantly superior in the study group (P < 0.05). ④ During follow-up, the incidence of major cardiovascular and cerebrovascular events was 6% in the study group and 9% in the routine group, with no significant difference (P = 0.421), indicating good safety of the general practice management model. Conclusion: The general practice management model significantly improves blood pressure control, depressive symptoms, and quality of life in community-dwelling disabled elderly patients with hypertension, without increasing the risk of cardiovascular and cerebrovascular events. As an important practice of “holistic, continuous, and integrated” care, this model is suitable for managing chronic diseases in disabled elderly individuals and deserves broader implementation in community health services.