2024 年第 3 期 第 19 卷

三级甲等医院全科医学科-社区联合对社区老年高血压病/糖尿病患者健康管理的效果研究

Study on the effect of general medicine department of third class A hospital-community combination on the health management of elderly hypertension/diabetes mellitus patients in the community

作者：张若岩1张金佳1张启龙2赵稳稳1张敏1孙彦杰1王荣英1

英文作者：Zhang Ruoyan1 Zhang Jinjia1 Zhang Qilong2 Zhao Wenwen1 Zhang Min1 Sun Yanjie1 Wang Rongying1

单位：1河北医科大学第二医院全科医学科，石家庄050000；2河北省石家庄市东焦街道社区卫生服务中心，石家庄050000

英文单位：1Department of General Medicine the Second Hospital of Hebei Medical University Shijiazhuang 050000 China; 2Dongjiaojiedao Community Health Service Center of Shijiazhuang Hebei Province Shijiazhuang 050000 China

关键词：慢性病；全科医学科；社区；健康管理

英文关键词：Chronicdiseases;Generalpractice;Community;Healthmanagement

• 摘要：

• 目的 探讨三级甲等医院全科医学科-社区联合对社区老年高血压病/糖尿病患者健康管理的效果。方法 选取2022年3—9月石家庄市东焦街道社区65岁以上高血压病/2型糖尿病患者132例，按照随机数字表法分为对照组和观察组，各66例。对照组按照常规社区卫生服务中心慢性病管理措施进行管理；观察组开展三级甲等医院全科医学科-社区联合健康干预。比较干预前后2组的血压、血糖、用药依从性、躯体症状、疾病就诊情况。结果 本研究最终可评价管理效果患者共126例，2组各63例。干预后，2组高血压病患者收缩压、舒张压均低于干预前，且观察组均低于对照组［（141±13）mmHg（1 mmHg=0.133 kPa）比（146±16）mmHg、（83±9）mmHg比（86±9）mmHg］（均P<0.05）；2组糖尿病患者空腹血糖、餐后2 h血糖均低于干预前，且观察组均低于对照组［（7.2±1.1）mmol/L比（8.4±1.2）mmol/L、（11.5±1.7）mmol/L比（14.0±1.4）mmol/L］（均P<0.05）。观察组干预后用药依从性优于干预前且优于对照组，躯体症状优于干预前且优于对照组（均P<0.05）。研究期间，观察组出现疾病相关症状、门诊就诊、住院治疗比例均少于对照组（均P＜0.05）。结论 三级甲等医院全科医学科-社区联合管理老年高血压病/糖尿病患者，可以有效降低其血压、血糖水平，提升老年人用药依从性，减轻躯体症状、减少患者就诊和住院比例。

• Objective To explore the effect of the combination of general medicine department of third class A hospital-community combination on the health management of elderly hypertension/diabetes mellitus patients in the community. Methods From March to September 2022, 132 patients over 65 years old with hypertension/type 2 diabetes mellitus in Dongjiaojiedao community in Shijiazhuang were selected. Patients were divided into the control group and the observation group according to the random number table method, with 66 cases in each group. Routine health management and general medicine department and community joint health intervention in community health service centers were carried out for the control group and the observation group, respectively. The blood pressure, blood glucose, medication compliance, physical symptoms and medical treatment of the two groups were compared before and after intervention. Results Totally 126 cases were enrolled in the study finally, with 63 cases in each group. After intervention, systolic and diastolic blood pressure of hypertension patients in both groups were lower than those before intervention, and the observation group was lower than the control group ［（141±13）mmHg vs （146±16）mmHg,（83±9）mmHg vs （86±9）mmHg］（all P<0.05）; fasting blood glucose and 2 h postprandial blood glucose of diabetes mellitus patients in both groups were lower than those before intervention, and the observation group was lower than the control group［（7.2±1.1）mmol/L vs （8.4±1.2）mmol/L,（11.5±1.7）mmol/L vs （14.0±1.4）mmol/L］（all P<0.05）. The medication adherence of the observation group after intervention was better than that before the intervention and better than that of the control group, and the somatic symptoms were better than those before the intervention and better than those of the control group(all P<0.05). During the study, the proportion of patients with disease-related symptoms, outpatient visits, and hospitalizations in the observation group were less than those in the control group(all P<0.05). Conclusions  The joint management of the general medicine department and the community in the third class A hospital can effectively reduce the blood pressure and blood glucose level of the elderly patients with hypertension/diabetes mellitus, improve the medication compliance of the elderly, and reduce physical symptoms, patient visits and hospitalization ratios.