医联体-家庭签约服务制家庭式慢病管理模式的应用效果分析

Application effects analysis of medical-family contract service system in family chronic disease management mode

目的 探讨医联体-家庭签约服务制在家庭式慢病管理模式中的应用效果。方法 选取2014年2月~2016年2月在荔湾区逢源街12个居委会中随机抽取4个居委会单病种慢病居民共400例,其中高血压患者、糖尿病单病种患者各200例。高血压分成A、B两组,糖尿病分成C、D两组,每组100例,其中A、C两组患者为干预组,提供慢病管理及医联体-家庭签约制的家庭式慢病管理,B、D两组为对照组,提供一般慢病管理,分析比较干预组和对照组患者的自我管理能力和健康状况评分。结果 A组患者对高血压相关知识的了解程度、服用降压药物的依从性及家庭行为的改变率分别为100%、85%及96%,明显高于B组的94%、67%及93%,差异有统计学意义（P〈0.05）,C组患者对糖尿病相关知识的了解程度、服用降糖药物的依从性及家庭行为的改变率分别为99%、87%及97%,明显高于D组的92%、72%及93%,差异有统计学意义（P〈0.05）,干预组的健康状况、自我效能和管理行为评分均显著高于对照组,差异有统计学意义（P〈0.05）。结论 医联体-家庭签约服务制能明显改善患者的身体状况,有效提高家庭式慢病管理效果。

Objective To explore the application effects of medical-family contract service system in family chronic disease management mode.Methods 400 cases with single chronic disease in four neighborhood committees were ran- domly selected from February 2014 to February 2016 of 12 neighborhood committees in Liwan District Fengyuan Street, patients with single hypertension or diabetes was 200 cases respectively.Patients with hypertension were divided into A and B group,and patients with diabetes were divided into C and D group,and each group was 100 cases.Patients in A and C group were divided into intervention group and were given chronic disease management and family chronic dis- eases management of medical-family contract service system;patients in B and D group were divided into control group and were given general chronic disease management.Self management ability and health status score between interven- tion group and control group were analyzed and compared.Results Understanding of hypertension related knowledge, compliance with antihypertensive drugs and rate of change in family behavior in A group was respectively 100%,85% and 96%,obviously higher than respectively 94%,67% and 93% in B group,and the difference was statistically signifi- cant （P〈0.05）;understanding of diabetes related knowledge,compliance with antidiabetic drugs and rate of change in family behavior in C group was respectively 99%,87% and 97%,obviously higher than respectively 92%,72% and 93% in D group,and the difference was statistically significant （P〈0.05）;the health status,self efficacy and management be- havior score in the intervention group were obviously higher than those in the control group,and the difference was sta- tistically significant （P〈0005）.Conclusion Medical-family contract service system can improve patients＇ physical condi- tion obviously and enhance the effects of family chronic disease management effectively.