上海高境镇社区65岁以上老年慢病患者管理效果评估

来源:用户上传      作者:陈云峰 潘雅萍 陈洋

　　摘 要 目的：{查65岁以上老年人2020和2021年体检结果变化，评估慢病管理的效果，为更好地开展健康管理工作提供参考。方法：在2020年和2021年均参加65岁以上老年人免费体检者中，采用单纯随机抽样法抽取体检后纳入慢病管理的100例患者作为管理组，其中男性39名（39.0%），平均年龄（73.51±6.16）岁；女性61名（61.0%），平均年龄（72.26±5.45）；高血压患者65名，糖尿病患者22名，合并有高血压和糖尿病的患者13名；同时选取体检后未纳入慢病管理的100例患者作为对照组，其中男性46名（46.0%），平均年龄（71.67±4.89）岁；女性54名（54.0%），平均年龄（70.70±4.63）岁；高血压患者76名，糖尿病患者18名，合并有高血压和糖尿病的患者6名。采集两组体检数据进行回顾性调查。结果：管理组2年异常检出率较高的前三项均为腹部超声异常、血脂异常、体质量指数（BMI）异常；对照组2年异常检出率较高的前三项均为血脂异常、腹部超声异常、BMI异常。单因素分析结果显示，与对照组比较，管理组慢病管理后的空腹血糖、总胆固醇正常水平的比例较高，而BMI正常的比较较低，差异均有统计学意义（P<0.05）。多因素回归分析结果显示血压、空腹血糖、总胆固醇水平与签约管理有关（P<0.05）。结论：慢病管理改善老年慢病患者的血糖和总胆固醇水平，但对慢病患者BMI的管理尚有不足。应拓展慢病管理范围，完善重点人群签约建档，更好地开展居民健康管理工作。
　　关键词 慢病管理；老年人；体检；影响因素
　　中图分类号：R580 文献标志码：A 文章编号：1006-1533（2022）14-0050-04
　　引用文本 陈云峰， 潘雅萍， 陈洋. 上海高境镇社区65岁以上老年慢病患者管理效果评估[J]. 上海医药， 2022， 43（14）： 50-53， 57.
　　Evaluation of management effect of the elderly patients with chronic diseases over 65 years old in Gaojing Community of Shanghai
　　CHEN Yunfeng， PAN Yaping， CHEN Yang（Department of General Practice of Gaojing Community Health Service Center of Baoshan District， Shanghai， 200435， China）
　　ABSTRACT Objective： To investigate the changes of physical examination results of the elderly over 65 years old in 2020 and 2021， and evaluate the effectiveness of chronic disease management， so as to provide reference for better health management. Methods： The subjects were selected from those who participated in free physical examination for the elderly over 65 years old in 2020 and 2021， using the simple random sampling method， 100 patients who were included in chronic disease management after physical examination were selected as the management group， and there were 39 males（39.0%）， with an average age of（73.51±6.16） years； there were 61 females（61.0%）， with an average age of （72.26±5.45） years； there were 65 patients with hypertension， 22 patients with diabetes and 13 patients with hypertension and diabetes； 100 cases who were not included in the chronic disease management after the physical examination were selected as the control group， and there were 46 males（46.0%）， with an average age of （71.67±4.89） years； there were 54 females（54.0%）， with an average age of （70.70±4.63） years； there were 76 patients with hypertension， 18 patients with diabetes and 6 patients with hypertension and diabetes. The physical examination data of two groups were collected for retrospective investigation. Results： The first three items with higher 2-year abnormal rate in the management group were abnormal abdominal ultrasound， abnormal blood lipids， and abnormal body mass index（BMI）； the first three items with higher abnormality detection rate in the control group were dyslipidemia， abnormal abdominal ultrasound，and abnormal BMI. The results of univariate analysis showed that compared with the control group， the proportion of normal levels of fasting blood glucose and total cholesterol in the management group after chronic disease management was higher， the comparison of normal BMI was lower， and the difference was statistically significant（P<0.05）. Multivariate regression analysis showed that blood pressure， fasting blood glucose and total cholesterol levels were related to contract management（P<0.05）. Conclusion： Chronic disease management improves the blood glucose and total cholesterol levels of the elderly patients with chronic diseases， but the management of BMI of patients with chronic diseases is still insufficient. The scope of chronic disease management should be expanded， the signing and filing of the key groups should be improved， and residents’ health management should be better carried out.

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