社区卫生服务中心家庭医生慢性病预约门诊的实践

The practice of the chronic disease outpatient appointments of the family doctors in the community health service center

目的:探索社区卫生服务中心家庭医生实施慢性病预约门诊的方法和效果。方法:每个社区居民区配备1名家庭医生和1名社区护士实施慢性病预约门诊管理,考核对高血压和糖尿病的患者治疗依从性、规范管理率和控制率。结果:实施社区卫生服务中心家庭医生慢性病预约门诊1年后,高血压患者预约管理率达61.08%,高血压控制率由实施前的42.12%上升到68.17%;糖尿病患者预约管理率达68.85%,控制率由29.95%上升到37.89%。结论:社区卫生服务中心慢性病预约门诊与二、三级医院预约门诊有所不同,是提高患者管理依从性的重要途径,是家庭医生开展慢性病管理的重要措施,是提高社区慢性病管理效果的重要手段。

Objective: To explore the method and effect of the chronic disease outpatient appointment provided by general practitioners(GPs)in the community health service centers. Method: Every resident area was allocated a GP and a nurse to make the appointments and observe the rates of compliance, management and control for the patients with hypertension or diabetes. Results: After one year of practice, the appointment management rate of the hypertension rate was 61.08% and the blood pressure control rate rose from 42.12% to 68.17%. The appointment management rate of the diabetes patients was 68.85%, and the blood glucose control rate increased from 29.95% to 37.89%. Conclusion: The outpatient appointment in the community health service centers was different from the second and third general hospitals. The outpatient appointment in the community health service centers is an important way to improve the compliance of patients and is an important measure for the GP to conduct the chronic disease management and is also an important means to improve the effectiveness of the chronic disease management.