基于网络平台的全科医生服务对慢性病共病患者积极度及其健康结局的影响研究  

General practice service based on internet platform for health management of patients with multiple chronic conditions:a self-control study

作　　者：刘雪君[1] 王爽[1] 万荣荣 肖涣 郎朗[1] 赵心[1] 于晓松[1] Liu Xuejun;Wang Shuang;Wan Rongrong;Xiao Huan;Lang Lang;Zhao Xin;Yu Xiaosong(Department of General Practice,the First Affiliated Hospital of China Medical University,Shenyang 110001,China)

机构地区：[1]中国医科大学附属第一医院全科医学科,沈阳110001

出　　处：《中华全科医师杂志》2020年第8期698-703,共6页Chinese Journal of General Practitioners

基　　金：国家自然科学基金项目(71273279);辽宁省科技计划项目(2013225089);沈阳市科学技术计划项目(F13-221-9-62)。

摘　　要：目的:评价基于网络平台的全科医生服务对慢性病共病患者进行健康管理的效果。方法:2015年6月至2016年6月,全科医生及其团队基于网络平台,对某功能性社区626例慢性病共病患者提供为期1年的健康管理服务,包括健康咨询、膳食及运动指导、发布健康资讯、建立健康档案和合理用药指导5项个体化健康管理计划。比较干预前、干预中(干预6个月)、干预后(干预1年)患者的积极度、生命质量、临床指标的改善情况,并分析患者积极度和生命质量之间的关系。结果:626例患者中,536例完成为期1年的干预,失访率为14.38%(90/626)。干预前、中、后患者的生理机能、生理职能、一般健康状况、精力、社会功能、情感职能、精神健康、整体生命质量评分均有所增加(F值分别为12.350、13.215、10.515、29.114、42.972、10.951、89.783、33.311,均P<0.05);BMI、腰围、收缩压、舒张压、总胆固醇、甘油三酯、低密度脂蛋白胆固醇、空腹血糖水平均有所降低(F值分别为30.039、33.849、7.152、27.453、59.938、214.270、73.488、62.014,均P<0.05);高密度脂蛋白胆固醇增加(F=16.491,P<0.01);积极度总分增加(F=9.471,P<0.01),积极度水平分级发生变化(χ^2=16.183,P<0.05);但躯体疼痛评分(F=1.486,P=0.227)无变化;积极度与一般健康状况(r=0.099,P=0.013)、精力(r=0.101,P=0.011)、精神健康评分(r=0.099,P=0.013)存在弱相关。结论:全科医生基于网络平台对慢性病共病患者进行健康管理,可提高患者积极度水平,改善患者的健康结局。Objective To evaluate the effect of general practice service based on network platform in health management of patients with multiple chronic conditions(MCC).Methods Based on network platform,the general practitioners provided health management service for 626 MCC patients in a petrochemical company in Panjin city of Liaoning province from June 2015 to June 2016.The individualized health management plan included health counseling,diet and exercise guidance,health information delivery,health file establishment,and rational medication guidance.After intervention the patient activeness,quality of life,clinical variables were evaluated.Results Ninety participants dropped out of study(14.38%,90/626),the questionnaire survey was conducted in rest 536 participants.After 1-year intervention,the scores of physical functioning,role-physical,general health,vitality,social functioning,role-emotional,mental health,and total scores in SF-36 were significantly increased(F=12.350,13.215,10.515,29.114,42.972,10.951,89.783 and 33.311,respectively,all P<0.05);the values of BMI,waist,systolic and diastolic blood pressure,total cholesterol,triglycerides,low density lipoprotein cholesterol,fasting blood glucose were significantly decreased(F=30.039,33.849,7.152,27.453,59.938,214.270,73.488 and 62.014,respectively,all P<0.05);the values of high density lipoprotein cholesterol were markedly increased(F=16.491,P<0.01);the overall scores of activation were increased(F=9.471,P<0.01),the level of activation was changed(χ^2=16.183,P<0.05);but there was no change in body pain(F=1.486,P=0.227).There was a weak correlation between patient activation and the general health(r=0.099,P=0.013),vitality(r=0.101,P=0.011),mental health(r=0.099,P=0.013).Conclusion General practice service based on network platform is feasible and effective for patients with multiple chronic conditions,after the implementation,the activation and the health outcomes are improved significantly.

关 键 词：慢性病 共病现象 全科医生 患者积极度 网络平台 

分 类 号：R197.1[医药卫生—卫生事业管理]