家庭医生制度下对社区骨质疏松症患者签约管理的探索与观察

Exploration and observation of contract management for community osteoporosis patients under the family doctor system

目的按照家庭医生制度要求,对社区骨质疏松症“1+1+1”签约的患者进行规范化管理,观察并探索社区慢性病管理的有效方法。方法随机抽取2016年12月—2018年12月五里桥街道社区卫生服务中心门诊诊断为"骨质疏松症"的常住本街道人口226例,根据自愿签约情况分为签约组和非签约组,2组均建立健康档案,签约组给予健康宣教、医患互动和预约随访,观察1年后2组骨转换标志物、双能X线吸收检测和中国人骨质疏松症专用生存质量量表等指标的变化情况。结果管理后,签约组骨转换标志物β-胶原降解产物、Ⅰ型前胶原氨基端前肽、骨钙素、甲状旁腺激素明显下降,差异具有统计学意义(均P<0.05);羟基维生素D、钙升高,差异具有统计学意义(均P<0.001)。签约组患者腰1、股骨颈、髋部的骨密度有提高,差异具有统计学意义(均P<0.05)。签约组患者中国人骨质疏松症专用生存质量量表(COQOL)下降程度明显优于非签约组,差异有统计学意义(均P<0.05)。结论家庭医生“1+1+1”签约管理,不仅为患者提供了方便、价廉的医疗服务,也改善了骨质疏松症患者的综合管理效果。

Objective According to the requirements of family doctor system,to standardize the management of the com-munity osteoporosis patients who signed the contract of"1+1+1",and observe and explore the effective methods of chronic disease management in the community.Methods Total 226 cases of permanent residents in this street diagnosed as"osteoporosis"in the Outpatient Clinic of Wuliqiao Sub-district Community Health Service Center from December 2016 to December 2018 were randomly selected and divided into signed groups and non-signed group.The signed group was given health education,doctor-patient interaction and appointment follow-up.The changes in bone turnover markers,du-al-energy X-ray absorptiometry,and Chinese osteoporosis-specific quality of life scales were observed after one year.Results The bone turnover markersβ-collagen degradation products,type I procollagen amino terminal propeptide,os-teocalcin,parathyroid hormone in the signed group were decreased significantly(all P<0.05),while the hydroxyvitamin D and calcium elevation were increased(all P<0.001).The bone density of waist 1,femoral neck and hip in the signed group were improved(all P<0.05).The Chinese People's Osteoporosis Special Quality of Life Scale(COQOL)in the signed group was significantly lower than that in the non-signed group(all P<0.05).Conclusion Family doctor"1+1+1"contract management not only provides convenient and cheap medical services for patients,but also improves the comprehensive management effect of osteoporosis patients.