老年人健康体检后跟踪服务研究.docVIP

老年人健康体检后跟踪服务研究 　　摘 要 目的：研究在老人体检后家庭医生跟踪服务效果及对家庭医生工作制的影响。方法：抽取2013年1月至2014年12月辖区内1 370名体检发现有异常的60岁及以上老人，对其中540人作为跟踪服务组，进行跟踪服务，包括一对一的体检报告解读、健康教育、健康咨询、健康危险因素分析与指导、疾病管理等，830人作为对照组，不进行跟踪服务。比较跟踪服务前后老人体检结果、健康生活方式改善以及体检满意度等情况。结果：对两组体检数据进行比较，血糖、三酰甘油、胆固醇、体质指数差异均无统计学意义（P均0.05）。对照组830人中749人（90.2%）对体检过程满意，150人（18.1%）对体检报告全面理解，124人（14.9%）知晓如何处理异常指标；跟踪服务组540人均对体检满意（100.0%），360人（66.7%）对体检报告全面理解，375人（69.4%）知晓如何处理异常指标，跟踪服务前后比较差异有统计学意义（P0.05）。结论：跟踪服务在疾病防治方面发挥了重要作用，有利于家庭医生制工作的开展。 　　关键词 疾病管理 体检 跟踪服务 　　中图分类号：R197.1/R194.3 文献标识码：A 文章编号：1006-1533（2015）18-0046-02 　　Research of the follow-up service after the elderly health examination 　　LI Li， ZHANG Chunmin 　　（Xinqiao Community Health Service Center of Songjiang District， Shanghai 201612， China） 　　ABSTRACT Objective： To study the effect of the follow-up service by the family doctors and the influence on their working system after the elderly health examination. Methods： Within the jurisdiction， 1 370 elderly people aged 60 and over who were found abnormal in the physical examination were selected from Jan. 2013 to Dec. 2014 and 540 of them were as the group of the follow-up service， and received the follow-up service， which included the interpretation of the medical report one to one， health education， health counseling， health risk factor analysis and guidance， disease management and others. Eight hundred and thirty were as the control group. The results of before and after the physical examination， improvement of the healthy life style， satisfaction for the physical examination and others were compared. Results： The difference in the blood glucose， triglycerides， cholesterol， and BMI had no statistical significance in comparison of the physical examination data in two groups （P0.05）. In the control group of 830 people， 749 （90.2%） satisfied with the process of the physical examination， 150 （18.1%） comprehensively understood the physical examination reports， and 124 （14.9%） knew how to deal with the abnormal index. In the follow-up