儿童高血压规范化诊疗管理方案在北京市基层医疗卫生机构推广应用效果评价

Evaluation of the implementation effect of the standardized diagnosis and treatment management program for childhood hypertension in primary healthcare institutions in Beijing

摘要

目的 探讨在北京市基层医疗卫生机构推广应用儿童高血压规范化诊疗管理方案（“COME 方案”）对儿童高血压检出率及控制率、基层医务人员管理水平等的影响，验证其可行性与有效性。方法 在北京市 4 个区遴选 4 家基层医疗卫生机构，按干预组与对照组各 2 家进行随机分组。干预组使用“COME 方案”（C：儿童高血压的筛查诊断流程；O：靶器官损害评估方法；M：上下联动闭环管理；E：推广效果评估）对高血压儿童进行干预，对照组仅维持日常医疗模式下儿童高血压防治状态。随访 1 年，共纳入 333 例高血压儿童（干预组 166 例、对照组 167 例）。比较两组基线资料及随访 1 年后的血压控制率（血压＜P₉₀）、血压达标率（血压＜P₉₅）、体重指数、收缩压及舒张压下降均值、体重指数下降均值、超重肥胖率、靶器官损害指标。在培训 1 年后，纳入参与培训的基层医生（城区干预组 13 名和郊区干预组 4 名）评估培训效果，同时，评估“COME 方案”的推广应用成效。结果 两组入组时一般基线资料差异无统计学意义（P＞0.05）。随访 1 年后，干预组儿童血压控制率（76.5% 比 40.1%，χ² = 45.32， P＜ 0.01） 及达标率 （86.1% 比 55.1%， χ² =38.66， P＜ 0.01） 高于对照组 ； 收缩压下降幅度 [14.4（95%CI： 13.4～ 15.5） 比 3.7（95%CI： 2.5～ 4.9） mmHg， t=13.03， P＜ 0.01]、 舒张压下降幅度 [8.8（95%CI： 7.6～ 10.1） 比 –0.6（95%CI： −2.0～ 0.7） mmHg， t=9.94， P＜ 0.01] 及体重指数下降幅度 [2.6（95%CI： 2.5～ 3.0） 比 1.4（95%CI： 1.2～1.6）kg/m²，t=8.05，P＜0.01] 更大；超重肥胖率较对照组降低（56.6% 比 68.9%，χ² =5.33，P＜0.05）。随访 1 年后，两组尿微量白蛋白及左心室质量指数差异亦存在统计学意义（P＜0.05）。干预后，干预组基层医生理论知识掌握率中位数（P₂₅，P₇₅）由 39.0%（29.5%，50.0%） 提高至 67.0%（63.0%，70.0%）（Z=−4.57，P＜0.01），操作技能得分率由 65.0%（56.0%，67.0%）提升至 85.0%（81.5%，88.0%）（Z=−4.99，P＜0.01）。“COME 方案”应用 1 年后，高血压儿童的体检测压率 、 高血压检出率 、 规范管理率和血压控制率分别达到 99.6%、 5.8%、 89.3% 和 77.1%。结论 “COME 方案”在基层医疗卫生机构的初步应用，可有效改善儿童血压及肥胖率，提升基层医务人员对儿童高血压诊治管理能力，显示出良好的效果和推广潜力。

Abstract

Objective To explore the impact of implementing the standardized diagnosis and treatment management program for childhood hypertension (“COME Program”) in primary healthcare institutions across Beijing on hypertension detection and control rates among children, as well as on the clinical management capacity of primary healthcare professionals, thereby assessing its feasibility and effectiveness. Methods Four primary healthcare institutions from four districts in Beijing were selected and randomly divided into an intervention group and a control group (two institutions per group). The intervention group applied the “COME Program” (C: criterion; O: organ damage; M: management; E: evaluation) to manage children with hypertension, while the control group maintained routine care. The follow-up period was one year. A total of 333 children with hypertension were enrolled (166 in the intervention group and 167 in the control group) and followed up for one year. Baseline characteristics and post-intervention outcomes—including blood pressure control rate (＜ P₉₀), blood pressure achievement rate (＜ P₉₅), reduction in systolic blood pressure and diastolic blood pressure, reduction in body mass index, prevalence of overweight and obesity and target organ damage indicators—were compared between groups. One year after training, the enrolled primary care physicians (13 from the urban intervention group and 4 from the suburban intervention group) were assessed for training effectiveness. Additionally, the implementation effectiveness of the "COME Program" was evaluated. Results No significant differences were found in baseline characteristics between groups (P＞0.05). After one year, the intervention group showed significantly higher blood pressure control (76.5% vs 40.1%, χ²=45.32, P＜ 0.01) and target achievement rates (86.1% vs 55.1%, χ²=38.66, P＜ 0.01) than the control group. Mean reductions in systolic blood pressure (14.4 [95%CI: 13.4 to 15.5] vs 3.7 [95%CI: 2.5 to 4.9] mmHg; t=13.03, P＜0.01) and diastolic pressure (8.8 [95%CI: 7.6 to 10.1] vs –0.6 [95%CI: −2.0 to 0.7] mmHg, t=9.94, P＜0.01) and body mass index (2.6 [95%CI: 2.5 to 3.0] vs 1.4 [95%CI: 1.2 to 1.6] kg/m², t=8.05, P＜ 0.01) were greater in the intervention group. Overweight/obesity rates decreased significantly compared with controls (56.6% vs 68.9%, χ² =5.33, P＜ 0.05). There were also significant statistical differences in the target organ damage indicators—urinary microalbumin, and left ventricular mass index. Theoretical knowledge mastery rate (median [P25, P75]) of community physicians improved from 39.0% (29.5%, 50.0%) to 67.0% (63.0%, 70.0%) (Z=−4.57, P＜ 0.01), and percentage score for practical skills from 65.0% (56.0%, 67.0%) to 85.0% (81.5%, 88.0%) (Z=−4.99, P＜0.01). After one year of implementation, the rates of blood pressure screening, hypertension detection, standardized management, and blood pressure control in children reached 99.6%, 5.8%, 89.3%, and 77.1%, respectively. Conclusion The initial implementation of the "COME Program" in primary healthcare institutions has effectively improved children's blood pressure and obesity rates, significantly enhanced the ability of primary healthcare professionals in the diagnosis, treatment, and management of childhood hypertension, and demonstrates favorable outcomes and potential for promotion.

关键词

高血压 / 儿童 / 基层医疗卫生机构 / COME 方案 / 推广 / 效果评价

Key words

hypertension / children / primary healthcare institutions / COME Program / promotion / effect evaluation

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基金资助

首都卫生发展科研专项(首发 2022-3-2105)

北京市医院管理中心临床医学发展专项(YGLX202532)

首都儿科研究所临床研究培育专项(LCYJ-2023-26)