海南省基层慢性病“1+1+1”管理模式效果分析

王慧; 顾申红; 张云波; 宋艳玲; 纪新博; 胡诗凌

doi:10.16766/j.cnki.issn.1674-4152.004450

海南省基层慢性病“1+1+1”管理模式效果分析

doi: 10.16766/j.cnki.issn.1674-4152.004450

王慧^{1, 2, 3},
顾申红^1, ,,
张云波¹,
宋艳玲¹,
纪新博¹,
胡诗凌⁴

1.
海南医科大学第一附属医院全科医学科，海南海口 570100
2.
海南医科大学第一临床医学院，海南海口 570100
3.
海南现代妇女儿童医院健康管理中心，海南海口 570100
4.
海南现代妇女儿童医院新生儿科，海南海口 570100

基金项目:

2022年度海南自贸港深化医改重点课题琼医改办〔2023〕4号

详细信息

通讯作者:
顾申红，E-mail：1574063710@qq.com

中图分类号: R499 R592
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出版历程
- 收稿日期: 2025-03-17

Analysis of the effectiveness of the "1+1+1" management model for chronic disease management at the primary level in Hainan Province

WANG Hui^{1, 2, 3},
GU Shenghong^{1
, ,},
ZHANG Yunbo¹,
SONG Yanling¹,
JI Xinbo¹,
HU Shiling⁴

1.
Department of General Medicine, First Affiliated Hospital of Hainan Medical University, Haikou, Hainan 570100, China

摘要

摘要: 目的比较海南省基层医疗卫生机构中不同管理模式对慢性病患者的管理效果，旨在优化慢性病患者的管理模式。方法选择海南省19个基层医疗机构2017年1月—2021年1月管理的915例慢性病患者，按随机数字表法分为对照组(463例)和干预组(452例)。对照组给予常规管理，干预组采用慢性病1+1+1管理。2年后收集患者的基础资料、管理控制指标、生活运动指标及满意度情况等相关数据并进行比较。结果干预2年后，干预组空腹及餐后2 h血糖、糖化血红蛋白、甘油三酯、饮酒及住院率分别为(6.99±1.58)mmol/L、(10.15±2.15)mmol/L、(6.25±0.83)%、1.66(1.26, 2.40) mmol/L、22.8%(103例)和17.0%(77例)，低于对照组的(6.40±2.19)mmol/L、(8.70±2.86)mmol/L、(5.69±1.04)%、1.06(0. 60, 1.80) mmol/L、44.1%(204例)和31.5%(146例)，差异有统计学意义(P < 0.05)；干预组服药完全依从、管理率、体育锻炼分别为412例(91.2%)、412例(91.2%)、333例(73.7%)，高于对照组的377例(81.4%)、354例(76.5%)、186例(40.2%)，差异有统计学意义(P < 0.05)。结论在基层医疗卫生机构采用慢性病1+1+1管理对慢性病患者管理的效果优于常规管理。
- 慢性病 /
- 慢性病管理 /
- 基层 /
- 海南省
Abstract: Objective By comparing the management effects of different management models on patients with chronic disease in primary healthcare institutions in Hainan Province, this study aimed to optimize the management model for chronic disease patients. Methods From January 2017 to January 2021, 915 patients with chronic diseases were randomly selected from 19 primary healthcare institutions in Hainan Province. They were divided into a control group (n=463) and an intervention group (n=452) using a random number table method. The control group received routine management, while the intervention group received chronic disease "1+1+1" management model. Basic information, management control indicators, lifestyle and exercise indicators, and patient satisfaction data were collected and compared after 2 years. Results After 2 years of intervention, the fasting and 2-hour post-meal blood glucose, glycosylated hemoglobin, triglycerides, alcohol consumption and hospitalization rates in the intervention group were (6.99±1.58) mmol/L, (10.15±2.15) mmol/L, (6.25±0.83)%, 1.66(1.26, 2.40) mmol/L, 22.8% (103 cases) and 17.0% (77 cases), respectively, which were lower than those in the control group [(6.40±2.19) mmol/L, (8.70±2.86) mmol/L, (5.69±1.04)%, 1.06(0. 60, 1. 80) mmol/L, 44.1% (204 cases) and 31.5% (146 cases)], and the differences were statistically significant (P < 0.05); the complete medication compliance, management rate, physical exercise and satisfaction rates in the intervention group were 412 cases (91.2%), 412 cases (91.2%), 333 cases (73.7%), respectively, which were higher than those in the control group [377 cases (81.4%), 354 cases (76.5%), 186 cases (40.2%)], and the differences were statistically significant (P < 0.05). Conclusion The application of the chronic disease "1+1+1" management model in primary healthcare institutions is more effective than conventional management in managing chronic disease patients.
- Chronic diseases /
- Chronic disease management /
- Primary healthcare level /
- Hainan Province
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表 1 2组慢性病患者基线资料比较[例(%)]

Table 1. Comparison of baseline characteristics between two groups of patients with chronic diseases [cases (%)]

项目	总体(n=915)	对照组(n=463)	干预组(n=452)	统计量	P值
性别				0.467^a	0.495
男性	472(51.6)	244(52.7)	228(50.4)
女性	443(48.4)	219(47.3)	224(49.6)
年龄				0.764^b	0.445
35~44岁	110(12.0)	51(11.0)	59(13.1)
45~59岁	278(30.4)	144(31.1)	134(29.6)
60~79岁	478(52.2)	238(51.4)	240(53.1)
≥80岁	49(5.4)	30(6.5)	19(4.2)
婚姻状况				0.935^a	0.817
未婚	36(3.9)	21(4.5)	15(3.3)
已婚	785(85.8)	394(85.1)	391(86.5)
离异	22(2.4)	11(2.4)	11(2.4)
丧偶	72(7.9)	37(8.0)	35(7.7)
文化程度				0.477^b	0.633
初中及以下	498(54.4)	257(55.5)	241(53.3)
高中/中专	287(31.4)	139(30.0)	148(32.7)
大专及以上	130(14.2)	67(14.5)	63(13.9)
注：^a为χ²值，^b为Z值。

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表 2 2组慢性病管理患者干预前后体检相关指标比较(x±s)

Table 2. Comparison of physical examination indicators before and after intervention between two groups of chronic disease management patients (x±s)

组别	例数	收缩压(mmHg)		舒张压(mmHg)		腰围(cm)		BMI(kg/m²)		空腹血糖(mmol/L)
组别	例数	干预前	干预后	干预前	干预后	干预前	干预后	干预前	干预后	干预前	干预后
对照组	463	138.85±14.98	139.16±14.43	89.54±11.45	88.41±10.52	81.94±9.67	81.71±11.31	23.73±3.74	23.45±4.02	7.09±1.74	6.99±1.58
干预组	452	138.91±15.66	134.35±15.01^b	89.96±12.22	83.13±10.90^b	82.52±9.56	82.25±12.2	23.98±3.44	23.62±4.26	7.19±1.71	6.40±2.19^b
统计量		0.055^a	4.949^c	0.543^a	7.456^c	0.902^a	0.697^c	1.054^a	0.589^c	0.918^a	4.682^c
P值		0.956	< 0.001	0.588	< 0.001	0.367	0.486	0.292	0.556	0.359	< 0.001

组别	例数	餐后2h血糖(mmol/L)		糖化血红蛋白(%)		胆固醇(mmol/L)		甘油三酯(mmol/L)
组别	例数	干预前	干预后	干预前	干预后	干预前	干预后	干预前		干预后
对照组	463	10.45±3.65	10.15±2.15	6.29±1.45	6.25±0.83	5.45±1.06	5.39±0.93	1.56(1.08, 2.28)		1.66(1.26, 2.40)
干预组	452	10.68±3.88	8.70±2.86^b	6.29±1.51	5.69±1.04^b	5.44±1.12	5.34±0.88	1.49(1.03, 2.23)		1.06(0.60, 1.80)^b
统计量		0.915^a	8.637^c	0.032^a	9.006^c	0.219^a	0.882^c	1.067^a		10.444^c
P值		0.360	< 0.001	0.975	< 0.001	0.827	0.378	0.286		< 0.001
注：^a为t值，^c为F值。与干预前比较，^bP < 0.05。

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表 3 2组慢性病患者干预前后服药依从性比较[例(%)]

Table 3. Comparison of medication adherence before and after intervention between two groups of patients with chronic diseases [cases (%)]

组别	例数	干预前			干预后			Z值	P值
组别	例数	不依从	部分依从	完全依从	不依从	部分依从	完全依从	Z值	P值
对照组	463	42(9.1)	61(13.2)	360(77.8)	32(6.9)	54(11.7)	377(81.4)	1.504	0.133
干预组	452	29(6.4)	52(11.5)	371(82.1)	11(2.4)	29(6.4)	412(91.2)	5.185	< 0.001
Z值		1.696			4.325
P值		0.090			< 0.001

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表 4 2组慢性病患者干预前后生活方式及行为改变情况比较[例(%)]

Table 4. Comparison of lifestyle and behavioral changes before and after intervention between two groups of patients with chronic diseases [cases (%)]

组别	例数	高盐饮食		高脂饮食		吸烟		饮酒		体育锻炼
组别	例数	干预前	干预后	干预前	干预后	干预前	干预后	干预前	干预后	干预前	干预后
对照组	463	368(79.5)	354(76.5)	291(62.9)	281(60.7)	310(67.0)	300(64.8)	214(46.2)	204(44.1)	178(38.4)	186(40.2)
干预组	452	357(79.0)	242(53.5)^a	267(59.1)	153(33.8)^a	316(69.9)	288(63.7)	217(48.0)	103(22.8)	164(36.3)	333(73.7)
χ²值		0.035	52.900	1.374	66.088	0.925	0.116	0.294	46.425^a	0.457	104.559^a
P值		0.852	< 0.001	0.241	< 0.001	0.336	0.734	0.588	< 0.001	0.499	< 0.001
注：与干预前比较，^bP < 0.05。

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表 5 2组慢性病患者干预前后规范管理率、控制率比较[例(%)]

Table 5. Comparison of standardized management rate and control rate before and after intervention between two groups of patients with chronic diseases [cases (%)]

组别	例数	规范管理		控制
组别	例数	干预前	干预后	干预前	干预后
对照组	463	338(73.0)	354(76.5)	172(37.1)	187(40.4)
干预组	452	320(70.8)	412(91.2)^a	162(35.8)	302(66.8)^a
χ²值		0.551	36.218	0.169	64.19
P值		0.458	< 0.001	0.681	< 0.001
注：与干预前比较，^aP < 0.05。

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表 6 2组慢性病患者干预前后住院率比较[例(%)]

Table 6. Comparison of hospitalization rates before and after intervention between two groups of patients with chronic diseases [cases (%)]

组别	例数	住院		χ²值	P值
组别	例数	干预前	干预后	χ²值	P值
对照组	463	163(35.2)	146(31.5)	1.354	0.282
干预组	452	154(34.1)	77(17.0)	37.023	< 0.001
χ²值		0.130	26.083
P值		0.718	< 0.001

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表 7 2组慢性病患者干预后对慢性病管理满意度情况比较[例(%)]

Table 7. Comparison of satisfaction with chronic disease management after intervention between two groups of patients with chronic diseases [cases (%)]

组别	例数	很满意	满意	一般	不满意	很不满意
对照组	463	20(4.3)	112(24.2)	224(48.4)	76(16.4)	31(6.7)
干预组	452	41(9.1)	141(31.2)	224(49.6)	33(7.3)	13(2.9)
注：2组比较，Z=5.408，P < 0.001。

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