开展家庭医生预约门诊服务对高血压合并糖尿病患者管理的效果分析  

Effect of family doctor appointment outpatient service in the management of patients with hypertension complicated with diabetes

作　　者：林盛强 王金明 LIN Sheng-qiang;WANG Jin-ming(Foshan Shunde District Lecong Community Health Service Center, Foshan 528315, Guangdong, CHINA;School of Public Health, Guangzhou Medical University, Guangzhou 511436, Guangdong, CHINA)

机构地区：[1]佛山市顺德区乐从社区卫生服务中心,广东佛山528315 [2]广州医科大学公共卫生学院,广东广州511436

出　　处：《海南医学》2018年第12期1759-1762,共4页Hainan Medical Journal

基　　金：广东省佛山市科技局自筹经费类科技计划项目(医学类科技攻关;编号:2016AB003373)

摘　　要：目的探讨开展家庭医生预约门诊服务,实施规范化管理对提高高血压合并糖尿病患者的健康管理效果。方法 2015年6月至2016年6月,采取整群抽样方法选取佛山市顺德区乐从社区卫生服务中心路州卫生站管理的124例已与家庭医生签约的高血压合并糖尿病患者为研究对象,按照随机数表法分为观察组和对照组各62例。观察组在家庭医生签约服务包基础上实施家庭医生预约门诊服务,由家庭医生对患者进行一对一的规范化干预,包括用药监测、健康评估、制定健康改善服务计划、健康指导和定期随访等;对照组患者由家庭医生团队按照家庭医生签约服务包进行常规管理。观察随访1年后,比较两组患者血压、血糖、服药依从性和生活行为的变化。结果观察组患者的收缩压、舒张压、平均空腹血糖分别为(134.34±9.43)mm Hg、(78.11±10.61)mm Hg、(6.59±1.14)mmol/L,明显低于对照组的(140.03±7.93)mm Hg、(84.24±8.62)mm Hg、(7.18±1.05)mmol/L,差异均有统计学意义(P<0.05);观察组患者的服药依从性评分为(2.69±1.05)分,明显高于对照组的(2.03±1.24)分,差异有统计学意义(P<0.05);观察组患者的吸烟、饮酒、高盐饮食和缺乏运动的人数分别为10例、14例、12例、21例,较自身干预前的27例、37例、33例、47例和对照组的21例、26例、25例、32例明显降低,差异均有统计学意义(P<0.05)。结论基于家庭医生预约门诊服务下的规范化管理可以提高高血压合并糖尿病患者服药依从性,改善不良生活习惯,促进健康生活行为的形成,提升患者血压、血糖控制效果。Objective o explore the health management effect of developing family doctor appointment outpatient service and implementing standardized management on hypertensive patients with diabetes mellitus. Methods A total of 124 hypertensive patients with diabetes mellitus registered with family doctors in Foshan Shunde District Lecong Community Health Service Center were selected as the subjects by a cluster sampling method from June 2015 to June2016. According to random number table, the patients were divided into observation group and control group, with 62 patients in each group. The observation group implemented family doctor appointment outpatient service on the basis of a family doctor contract service, in which the patients received individualized and standardized management from the family doctor, including drug monitoring, health assessment, health improvement services, health guidance and regular follow-up. The control group were given routine management by the family doctor team in accordance with the contract service. The changes of blood pressure, blood glucose, drug compliance, and health behavior were compared between the two groups after 1 year of follow-up. Results The systolic pressure, diastolic pressure, and mean fasting blood glucose were（134.34 ± 9.43） mm Hg,（78.11 ± 10.61） mm Hg,（6.59 ± 1.14） mmol/L in the observation group, respectively, which were significantly lower than（140.03±7.93） mm Hg,（84.24±8.62） mm Hg,（7.18±1.05） mmol/L in the control group（P〈0.05）. The drug compliance score of the observation group was（2.69±1.05）, which was significantly higher than（2.03±1.24） of the control group（P〈0.05）. The number of patients with smoking, alcohol drinking, high salt diet, and lack of exercise in the observation group were 10 cases, 14 cases, 12 cases and 21 cases, respectively, which was significantly lower than 27 cases, 37 cases, 33 cases, 47 cases before intervention, and 21 cases, 26 cases, 25 cases and 32 cases in thecontrol group（P〈0.05�

关 键 词：高血压 糖尿病 预约门诊 健康管理 

分 类 号：R544.1[医药卫生—心血管疾病]