山区空巢老人慢性病管理带药上门随访模式研究

Study on follow-up with drugs mode for chronic diseases management of empty nesters in mountain areas

目的了解山区空巢老人慢性病管理现状,探索空巢老人慢性病管理带药上门随访模式效果,为山区空巢老年人健康管理策略选择提供依据。方法抽取丽水市3个县(区)共12个行政村空巢老年慢性病患者240例,按行政村随机分为带药随访组和对照组,根据年龄和性别匹配,进行社会人口经济学特征、基本健康情况及SF-36量表调查,并进行1年队列跟踪研究,分析带药随访模式对患者的健康状况及血压血糖等控制效果的影响。采用方差分析、LSD-t检验及Wilcoxon秩和检验等统计方法进行分析。结果带药随访12个月后,两组间收缩压(t=5.135)、空腹血糖(t=4.241)和总胆固醇(t=4.967)的指标差异有统计学意义(P<0.05);而其他指标差异无统计学意义(P>0.05)。带药随访组高血压患者服药率由干预前的46.13%提高到72.24%,控制率由50.24%提高到56.12%,规范管理率由60.21%提高到67.32%,与对照组相比,服药率、控制率和规范管理率均明显提高,差异均有统计学意义(P<0.05)。带药随访干预12个月后,患者生理功能、精神健康和总体健康得分均高于对照组患者,差异均有统计学意义(P<0.05),而其他5个维度得分差异均无统计学意义(P>0.05)。结论通过慢性病管理带药上门随访模式实施,带药随访组患者的服药率、控制率及规范管理率等有较明显提高,并且总体健康情况有较大改善,此模式在山区欠发达地区慢性病管理方面具有较大推广价值。

Objective To understand the current situation of chronic diseases management of empty nesters in mountain areas, and to explore the effect of follow-up with drugs mode for chronic diseases management of empty nesters, in order to provide the evidence for selecting health management strategies of empty nesters in mountain areas. Methods A total of 240 empty nest elderly patients with chronic diseases from 12 administrative villages in 3 counties(districts) of Lishui City were selected, and they were randomly divided into follow-up group and control group according to administrative villages. According to the match of age and gender, sociodemographic characteristics, basic health status and SF-36 scale were investigated. And one-year cohort tracking study was conducted to analyze the effects of follow-up with drugs mode on the patients’ health status and the control effect of blood pressure and blood glucose. Statistical methods such as analysis of variance, LSD-t test and Wilcoxon rank sum test were used for analysis. Results After 12 months of follow-up with drugs, there were significant differences in the indicators of systolic blood pressure(t=5.135), fasting blood glucose(t=4.241) and total cholesterol(t=4.967) between two groups(P<0.05);while other indicators showed no significant difference(P>0.05). In the follow-up group, the medication rate of the patients with hypertension increased from 46.13% to 72.24% after intervention, the control rate increased from 50.24% to 56.12%, and the standardized management rate increased from 60.21% to 67.32%. Compared with the control group, the medication rate, the control rate and the standardized management rate were all significantly increased, the differences were statistically significant(P<0.05). After 12 months of follow-up with drugs, the physiological function, mental health and overall health scores of the patients in the follow-up group were higher than those in the control group, the differences were statistically significant(P<0.05);while there were no significant differences in the other five dimensions(P>0.05). Conclusion Through the implementation of follow-up with drugs mode for chronic diseases management, the medication rate, control rate, and standardized management rate of the patients in the follow-up group have been significantly improved, and the overall health status has been greatly improved. This mode has great promotion value in the management of chronic diseases in underdeveloped areas in mountain areas.