体检后重要疾病(指标)跟踪随访探索

Follow Up of Important Diseases(Index) After Physical Examination

目的通过电话等多种形式对健康体检人群中重要指标异常者进行持续跟踪随访,达到肿瘤的早诊断、早治疗;其它疾病的及时诊治,慢病的有效管理。方法制定健康体检重要疾病(指标)标准,建立重要疾病(指标)跟踪库,对进入跟踪库患者进行以电话为主的跟踪随访。结果 7 000人次跟踪随访,恶性肿瘤原位癌诊断率(90.5%vs.36%)提高,随着跟踪随访率的增加,慢性病生活习惯改善率(65%vs.21%),慢性病就诊率(56%vs.9%)也得到提高。结论通过5年对重要疾病跟踪管理,肿瘤的漏诊率降低,其它疾病及时诊治率提高,慢性病管理卓有成效。

Objective To follow-up the population with important abnormal indicators in physical examination through telephone and other forms in order to carry on early diagnosis and early treatment of tumors, timely diagnosis and treatment of other diseases and effective management of chronic diseases. Methods Standards for important diseases（indicators） for physical examination and tracking libraries for important diseases（indicators） were established. Telephone-based follow-ups were conducted for patients in the tracking database. Results Based on tracking for 7 000 patients, the diagnostic rate of malignant tumor in situ（90.5% vs.36%） was significantly improved. With the increase of follow up rate, the rate of improvement of habits and habits of chronic diseases（65% vs.21%）, the rate of treatment for chronic diseases（56% vs.9%） was also significantly improved. Conclusion After 5 years of tracking and management of important diseases, the rate of missed diagnosis of tumors has been significantly reduced and other diseases have been diagnosed and treated in a timely manner. The management of chronic diseases is effective.