社区高血压患者急症风险预测模型构建及预见性干预与救护管理体系的研究

In China, the morbidity rate of hypertension is 18.8%, Which is the most common non-infectious chronic disease. Hypertensive emergencies, whose morbidity rate in hypertension patients is 5%, is the first risk factor resulted in death among people above 40-year-old in China. The poor quality of life，high mortality rate and the emergent onset is the characteristic of the hypertensive emergency. So far, the researches on hypertensive emergencies mainly concentrate on drug therapy, lacking pre-onset management, especially the intervention of pre-onset health management. Thus, the main purpose of this research is: to construct r Disease Prediction model basing on the analysis of the risk factors of the hypertension and hypertensive emergencies, and take stratified intervene in the patients according to the risk; to create predictable intervention model by exploring the contents, pattern, method and the way of predictable intervention based on the risk factors and characters of hypertensive emergencies’ development, and mainly implement intervention in high risk group of hypertensive emergencies; on the basis of the local health resources， to implement stratified management on the intervented people by “community-family-patient” as the core. And finally construct community hypertension patients’ emergencies risk forecasting model and predictable intervention, emergency management system, which could provide references when developing the aids and interventions of hypertensive emergencies in the community and formulating policies on sanitary control in the future..

我国高血压人群患病率18.8%，是最常见非传染性慢性病，高血压急症发病率占高血压患者的5%。是我国40岁以上人群总死亡的第一危险因素。高血压急症发病急、死亡率高，患者生存质量差。目前对高血压急症的救护管理多集中在药物治疗上，而对患者发病前的风险预测及管理鲜有报道。本研究通过分析高血压急症的危险因素，构建高血压急症风险预测模型；根据风险预测对高血压患者进行分层：高危组、中危组、低危组，针对每组的特点分别实施干预，以高危组为重点干预对象；另针对危险因素及急症的发病特点建立预见性干预模式，确定预见性干预的内容、形式、方法及途径；利用当地卫生资源，建立“社区-家庭-患者”的纵向救护管理系统对干预人群实施横向分层管理。据此构建社区高血压患者急症风险预测模型及预见性干预与救护管理体系。为未来社区内开展急症的救护与干预及卫生管理政策的制定提供参考。

我国高血压人群患病率18.8%，是最常见非传染性慢性病，高血压急症发病率占高血压患者的5%。是我国40岁以上人群总死亡的第一危险因素。高血压急症发病急、死亡率高，患者生存质量差。目前对高血压急症的救护管理多集中在药物治疗上，而对患者发病前的风险预测及健康管理鲜有报道。本研究通过分析高血压急症的危险因素，构建高血压急症风险预测模型；根据风险预测对高血压患者进行分层；针对危险因素及急症的发病特点建立预见性干预模式；构建社区高血压患者预见性干预与救护管理体系；通过对社区高血压急症患者实施预见性，跟踪随访评价其干预效果。聚焦于高血压急症这一人群，对心血管急症的防治，减少心血管急症危害意义重大。以往对高血压急症救护多着眼于医院，由专业医护人员参与实施，少有利用社区卫生资源开展急症救护。目前我国医疗资源缺乏，专业救护人员及救护物资有限，不利于急症的救护。因此，充分利用社区卫生资源开展急症救护，对急症的防治、救护、减少死亡及残疾率，提高患者生活质量,减少医疗资源消耗，解决医疗资源短缺意义重大，并顺应国家下达关于实施分级诊疗医疗政策；对高血压急症危险因素进行早期干预与救护管理，是一种效价比较高的健康管理策略，对控制高血压急症的发生和病情进展具有重要意义。