上海市社区深化老年人健康管理策略研究

Study on the Strategies of Deepening the Health Management of the Community Elderly in Shanghai

目的了解上海市社区老年人健康管理现况,分析存在的问题,提出深化管理的关键策略。方法对社区卫生服务中心进行抽样问卷调查、区级及社区层面的关键知情人访谈,对试点社区的骨质疏松单病种管理及数据分析;基于Markov模型构建社区骨质疏松转移频数矩阵和概率矩阵,计算质量调整生命年,测算增量成本效果比。结果共收回99份调查问卷。主要问题有需管理的人数太多、缺乏B超医师、管理对象不愿意体检等,缺乏分层分类及全程社区健康管理、后续老年人单病种管理。社区骨质疏松的发展趋势存在明显的转移频数和概率,这种单病种管理的干预较为有效。结论老年人健康管理需充分社区赋能、全程社区健康管理和开展单病种管理。

Objective To understand the current situation of health management of the elderly in community in Shanghai,analyze the existing problems,and put forward the key strategies of deepening management.Methods A questionnaire survey was conducted in community health service centers,interviews were conducted with key informants at district and community levels,and single disease management and data analysis were conducted in pilot communities;The transfer frequency matrix and probability matrix of osteoporosis in community were constructed based on Markov model to calculate the quality adjusted life year and the incremental cost-effectiveness ratio.Results A total of 99 questionnaires were investigated.The main problems were too many people to be managed,lack of B-ultrasound doctors,and management objects were unwilling to have physical examination.Lack of hierarchical classification and the whole process of community health management,follow-up single disease management of the elderly.The development trend of osteoporosis in community has obvious transfer frequency and probability,and the intervention of single disease management is more effective.Conclusion The elderly health management needs to be fully community empowerment,whole process community health management and single disease management.