家庭医生签约服务对老年慢性病患者的健康管理效果分析  

Analysis of the Effect of Family Doctor Contract Service on the Health Management of the Elderly

作　　者：庄雅向 ZHUANG Yaxiang(Jiaomei Community Health Service Center of Fujian Zhangzhou Taiwan Investment Zone,Zhangzhou,Fujian 363107,China)

机构地区：[1]福建省漳州台商投资区角美社区卫生服务中心,福建漳州363107

出　　处：《中国医药指南》2025年第11期130-133,共4页Guide of China Medicine

摘　　要：目的探讨家庭医生签约服务对老年慢性病患者健康管理的效果,分析其在血压、血糖控制以及并发症预防和患者满意度方面的影响。方法研究对象为角美社区卫生服务中心在2022年1月至2023年12月管理的80例老年慢性病患者,按是否签署家庭医生签约服务协议划分为观察组(40例)和对照组(40例)。观察组接受家庭医生的个性化健康管理服务,对照组仅接受常规随访。观察指标包括血压、血糖控制情况及达标率,患者疾病知晓程度及依从性和患者满意度。结果观察组的血压控制达标率和血糖控制达标率均高于对照组(均P<0.05)。观察组高血压和糖尿病患者的疾病知晓程度评分高于对照组(P<0.05)。观察组患者满意度评分高于对照组(P<0.05)。结论家庭医生签约服务通过个性化、系统化的健康管理,提高了老年慢性病患者的血压和血糖控制水平以及患者的疾病知晓程度和治疗依从性,此外也提升了患者的满意度,具有较高的应用价值。Objective To explore the effect of family doctor contract services on health management for elderly patients with chronic diseases,and to analyze its impact on blood pressure and blood sugar control,prevention of complications,and patient satisfaction.Methods A total of 80 elderly patients with chronic diseases managed by Jiaomei Community Health Service Center from January 2022 to December 2023 were selected as the research subjects.They were divided into an observation group(40 cases)and a control group(40 cases)based on whether they had signed a family doctor contract.The observation group received personalized health management services from family doctors,while the control group only received routine follow-ups.The observation indicators included blood pressure and blood glucose control levels and their respective attainment rates,patients’awareness of their diseases,compliance,and satisfaction.Results The blood pressure and blood glucose control attainment rates in the observation group were both higher than those in the control group(both P<0.05).The disease awareness scores of patients with hypertension and diabetes in the observation group were higher than those in the control group(P<0.05).The patient satisfaction scores in the observation group were higher than those in the control group(P<0.05).Conclusions Family doctor contract services,through personalized and systematic health management,have improved the blood pressure and blood glucose control levels of elderly patients with chronic diseases,as well as their awareness of the diseases and adherence to treatment.In addition,patient satisfaction has also been enhanced,indicating that this service model has considerable application value.

关 键 词：家庭医生签约 老年人健康 血压控制 血糖控制 效果分析 

分 类 号：R473.2[医药卫生—护理学]