Evaluation of the intervention effect of standardized follow-up management for elderly patients with multiple chronic diseases after physical examination screening
基层老年多病共存患者体检筛查后规范化随访管理的干预效果评价

摘要

目的 评价基层老年多病共存患者体检筛查后实施规范化随访管理的干预效果。方法 选取2025年3月-2026年3月期间在本院接受健康体检并检出多病共存的82例老年患者，随机分组，各41例。对照组实施常规基本公共卫生随访管理，观察组在常规随访基础上实施规范化随访管理方案。比较两组干预成效。结果 干预后，观察组临床指标（血压、血糖、血脂）及自我管理能力均显著优于对照组（P＜0.05）。结论 体检筛查后实施规范化随访管理可有效改善基层老年多病共存患者的临床指标，提升自我管理能力。

Abstract

Objective To evaluate the intervention effect of standardized follow-up management after physical examination screening in elderly patients with multimorbidity in primary care.
Methods A total of 82 elderly patients with multimorbidity detected during health examinations at our hospital from March 2025 to March 2026 were selected and randomly divided into two groups, with 41 cases in each group. The control group received routine basic public health follow-up management, while the observation group received standardized follow-up management based on routine follow-up. The intervention effects were compared between the two groups.
Results After intervention, the observation group showed significantly better clinical indicators (blood pressure, blood glucose, blood lipids) and self-management ability than the control group (P＜0.05).
Conclusion   Standardized follow-up management after physical examination screening can effectively improve clinical indicators and enhance self-management ability in elderly patients with multimorbidity in primary care.