陈宝欣　忽群　孙明伟　黄志杰　孙虹　刘丹　陈文如　周志衡　田华伟

【摘要】 目的：構建应用智能化平台的家庭医生团队“三师共管”慢性病管理模式，并评价其在社区老年慢性病患者中的应用效果。方法：搭建智能化健康管理平台，并于2018年6月起，选取深圳市福田区益田社区健康服务中心65岁以上的高血压患者和糖尿病老年患者各500例，采用以家庭医生团队为基础的“三师共管”管理模式对其进行为期1年的健康管理，比较患者干预前后的血压、血糖、BMI、生活方式等情况，分析其管理效果。结果：共482名高血压患者和479名糖尿病患者完成了1年的随访干预。干预后，高血压患者收缩压、舒张压、空腹血糖和BMI均显著低于干预前，差异均有统计学意义（P<0.05）。干预后，糖尿病患者的空腹血糖和BMI均显著低于干预前（P<0.05）。干预后，高血压和糖尿病患者吸烟和饮酒的比例均低于干预前，差异均有统计学意义（P<0.05）;干预后，高血压和糖尿病患者运动30 min以上的频率均显著多于干预前，差异均有统计学意义（P<0.05）。结论：基于家庭医生团队的“三师共管”慢性病管理模式对社区老年慢性病患者的健康管理效果满意，值得在社区中推广。

【关键词】 高血压 糖尿病 老年人 健康管理

Construction and Effect Evaluation of Health Management Model of Elderly Chronic Diseases in Community Under the "Three Divisions Co Management" of Family Doctor Team/CHEN Baoxin， HU Qun， SUN Mingwei， HUANG Zhijie， SUN Hong， LIU Dan， CHEN Wenru， ZHOU Zhiheng， TIAN Huawei. //Medical Innovation of China， 2020， 17（15）： 164-168

[Abstract] Objective： To construct the chronic disease management mode of “three divisions co management” of the family doctor team based on the intelligent platform， and to evaluate its application effect in the elderly chronic disease patients in the community. Method： Build an intelligent health management platform， and since June 2018， select 500 hypertension patients and 500 diabetes elderly patients over 65 years old in Yitian community health service center of Futian District， Shenzhen City， and used the “three division co management” management mode based on the family doctor team to carry out a one-year health management， the blood pressure， blood sugar， BMI and lifestyle of the patients before and after intervention were compared， and the management effect was analyzed. Result： A total of 482 hypertensive and 479 diabetic patients completed a 1-year follow-up intervention. After intervention， systolic blood pressure， diastolic blood pressure， fasting blood glucose and BMI in hypertensive patients were significantly lower than those of before intervention， with statistically significant differences （P<0.05）. After intervention， fasting blood glucose and BMI were significantly lower in patients with diabetes than those of before intervention （P<0.05）. After intervention， the proportion of smoking and drinking in patients with hypertension and diabetes were lower than those of before intervention， and the differences were statistically significant （P<0.05）. After intervention， the frequency of exercise for more than 30 min in patients with hypertension and diabetes were significantly higher than those of before intervention， and the differences were statistically significant （P<0.05）. Conclusion： Based on the family doctor team， “three division co management” chronic disease management model is satisfied with the health management effect of elderly chronic disease patients in the community， which is worth promoting in the community.

[Key words] Hypertension Diabetes Elderly Health management

First-authors address： Futian Hospital for Prevention and Treatment of Chronic Disease， Shenzhen 518048， China

doi：10.3969/j.issn.1674-4985.2020.15.042

随着我国进入老龄化社会，老年人慢性病患病率不断攀升，老年人的健康问题已成为我国亟待解决的社会问题[1-2]。自国家基本公共卫生规范项目启动以来，针对65岁以上的老年人慢性病管理规范逐步形成，并已取得一定的效果，但由于我国老年高血压和糖尿病患者数量庞大，我国目前没有公认的慢性病管理模式，高血压糖尿病健康管理模式仍在探索阶段[3-5]。随着健康管理师的推广，我国已培养了一批健康管理师。既往，厦门市率先探索了“三师共管”的慢性病管理模式，并取得不错的效果[6-8]。在深圳“三师共管”仍未推广，因此本研究以福田区益田社区健康服务中心为试点，探索构建应用智能化平台的家庭医生团队“三师共管”老年人慢性病管理模式，并评价其管理效果，现报道如下。……