家庭醫生簽約服務在老年慢性疾病健康管理中的應用效果

員戰民

[摘要] 目的 觀察家庭醫生簽約服務在老年慢性疾病健康管理中的應用效果。 方法 納入2018年1月至2019年12月的社區老年慢性疾病患者64例，隨機分為觀察組與對照組，每組各32例，分別實施家庭醫生簽約服務與常規社區健康管理。比較兩組患者健康知識評分及自我管理能力評分、血壓、血糖、血脂指標在干預前后的變化情況，隨訪患者遵醫依從性。 結果 干預后兩組患者健康知識評分、自我管理能力評分均較干預前升高，差異有統計學意義（P<0.05），且觀察組較對照組升高，差異有統計學意義（P<0.05）;干預前兩組患者較各項血糖、血脂及血壓指標比較，差異無統計學意義（P>0.05），干預后觀察組均優于對照組，差異有統計學意義（P<0.05）;觀察組合理飲食、適量運動、遵醫用藥、定期復查等遵醫行為高于對照組，差異有統計學意義（P<0.05）。 結論 家庭醫生簽約服務在老年慢性疾病健康管理中的應用，能夠提高患者健康認知及自我管理能力，促進各項臨床指標改善，提高患者醫囑依從性，值得臨床推廣。

[關鍵詞] 家庭醫生簽約服務;老年慢性病;健康管理;健康知識評分;自我管理能力

[中圖分類號] R592? ? ? ? ? [文獻標識碼] B? ? ? ? ? [文章編號] 1673-9701（2021）22-0090-04

Application effect of family doctor contract service in health management of chronic diseases in elderly

YUN Zhanmin

Department of General Practice， Central University Hospital for Nationalities， Beijing? ?100081，China

[Abstract] Objective To observe the effect of family doctor contract service in the health management of chronic diseases in the elderly. Methods A total of 64 patients data of elderly patients with chronic diseases in the community were included from January 2018 to December 2019. They were randomly divided into the observation group and the control group， with 32 cases in each group， and respectively treated with family doctor contract services and routine community health management. The changes of health knowledge， self-management ability score， blood pressure， blood glucose and blood lipid indexes before and after intervention were compared， and the medical compliance of patients was followed up. Results The scores of health knowledge and self-management ability were improved in both groups after intervention， compared with those before intervention （P<0.05）; those of the observation group were higher than those of the control group （P<0.05）， which were statistically significant. Before intervention， no statistically significant differences were observed in blood glucose， blood lipid and blood pressure indexes between the 2 groups （P>0.05）; after intervention， those of the observation group were better than those of the control group， and the differences were statistically significant （P<0.05）. Compared with the control group， better compliance behaviors such as reasonable diet， proper exercise， compliance with medical drugs and regular review were observed in the observation group （P<0.05）， with statistically significant differences. Conclusion The application of family doctor contract services in the health management of chronic diseases in the elderly can improve patients′ health cognition and self-management ability， promote the improvement of various clinical indicators， and improve patients′ compliance with medical advice， which is worthy of clinical promotion.