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ObjectiveInvestigate a community named Tian-hang in Hangzhou city of Zhejiang province which carries out the three graded management in patients with hypertension, and analyze its effect in this community. Enrich the community-based management of hypertension research system. Provide references for the management of chronic diseases in communities in China.MethodsThe patients with hypertension in Tian-hang community in2007-2009, was chosen as the object and analyze their information. The information was analyzed included the special files, follow-up data, satisfaction surveys, on-site interview data, and so on. These indicators were acquired in the end, such as the situation before and after management, medication, smoking, alcohol, salt, weight, community treatment rate changes, satisfaction condition, changes in management efficiency, physician responsibility, and responsibility of physician members of the hierarchical management team effectiveness and management at different levels to promote Evaluation of the sustainability factors.Results The results show: in Tian-hang community, there are 494 patients with hypertension in three grade management. The blood pressure control rate was from 21.5% in 2007 to 71% in 2009, and in high risk group, it decreased from 39.3% to 35%. The rate of taking drugs in standard increased from 37.1% to 86.3%. The rate of smoking decreased from 19.6% to 17.6%, and the rate of drinking decreased from 20.4% to 18%. The overweight and obesity rate increased from 25.5%,6.7% to 17.6%, 3%. The low-salt diet rate increased from 42.3% to 90.9%. Select community hospital rate increased from 26.7% to 76.9%. And there is a higher level of overall satisfaction in patients with hypertension. From 2007 to 2009, the awareness in responsibility physician was 60.2%,92%,96%; the satisfaction rate was 54%,70%,80%; the satisfaction in convenience was 92%,92%,98%; the satisfaction in security was 82%,96%,100%; the satisfaction in comfortable was 94%,98%,98%; the satisfaction in economy was 90%,92%,92%. The management efficiency of doctors gradually increased in 2007-2009, and the number of follow-up was 2319,3432, and 3703. In 2007, the management style was visits (76.9%); and in 2009, it was in clinic (47.2%) and telephone (26.5%). Then, the time-consuming decreased. Responsible physician said that three-level management is suitable. The important factors in it were team model, performance, computer information systems.ConclusionsThe three grade management in hypertension improves blood pressure control levels, life behavior, enhances the attendance rate of patients in community, self-management capabilities and satisfaction levels, and promotes the efficiency of management responsibility and management of physicians wills.
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