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目的了解慢性病管理效果指标达标情况,及时调整管理模式,为制定干预措施提供科学依据。方法收集2010年全县基本公共卫生服务项目慢性病管理的相关数据,随机抽取高血压、糖尿病病人各180人,依据2015年末随访的各项指标,与建档时的基本信息进行统计分析。结果血压的达标率由建档时的13.33%上升到随访时的37.22%(χ~2=27.19,P<0.01);血糖的达标率由建档时的43.33%上升到随访时的66.11%(χ~2=18.85,P<0.01);2015年随访时的高血压、糖尿病规范服药率较建档时都有非常显著提高,重度摄盐率明显下降(χ~2=25.46、19.78,P<0.01),每周锻炼运动率也有非常显著的增加(χ~2=7.99、4.54,P<0.01)。结论乐亭县基本公共卫生服务项目慢性病健康管理效果评估体系正在逐步完善,在探索慢性病管理模式的同时,将高血压和糖尿病的管理模式向其他慢性病防治进行推广。
Objective To understand the achievement of chronic disease management index, adjust the management mode in time and provide a scientific basis for formulating intervention measures. Methods The data of chronic diseases management of the basic public health service items collected in the county in 2010 were collected. 180 patients with hypertension and diabetes were randomly selected. Based on the follow-up indicators at the end of 2015, the data were analyzed statistically. Results The compliance rate of blood pressure increased from 13.33% at the time of filing to 37.22% at the follow-up (χ ~ 2 = 27.19, P <0.01). The compliance rate of blood glucose increased from 43.33% at the time of filing to 66.11% χ ~ 2 = 18.85, P <0.01). The standard rate of hypertension and diabetes mellitus at follow-up in 2015 was significantly higher than that at the time of filing, and the rate of severe salt intake was significantly decreased (χ ~ 2 = 25.46 and 19.78, P < 0.01). The weekly exercise rate also had a significant increase (χ ~ 2 = 7.99, 4.54, P <0.01). Conclusion The evaluation system of chronic disease health management in Laoting County basic public health service project is gradually being improved. While exploring the chronic disease management model, the management mode of hypertension and diabetes is promoted to other chronic disease prevention and control.