Abstract: Background　Chronic diseases have become the leading diseases threatening the health of Chinese people，which accounts for 80% of annual total deaths（10.3 million）．If we do not control this issue，the direct cost of treatment and the economic cost caused by the loss of labor force and health will increase the burden of individuals，enterprises and the government.We noted that community healthcare is the main playfield of chronic disease management.Objective　To study the management effect of community chronic diseases active reservation health management model on essential hypertension,and to promote family doctor's contracting work.Methods　In March 2017，450 patients with primary hypertension whose chronic diseases were managed by appointed outpatient follow-up service in Jinyang Community Health Service Center of Wuhou District were randomly selected as the study group，and 450 patients with primary hypertension who signed the contract service in other community healthcare centers in Wuhou District were selected as control group by using stratified randomized sampling method.The study group carried out the health management intervention by active appointments according to different disease grading，while the control group carried out routine management according to hypertension follow-up management standard in the National Basic Public Health Service Standard（the third edition）．Intervention period was from April 2017 to April 2018.The management effect was measured by the self -made questionnaire from 3 dimensions，including general data（gender，age，medical insurance，education，course of disease，complications），the quality of chronic disease management（blood pressure control rate，health expenditure for chronic diseases in past two weeks），patients satisfaction rate and work efficiency of staff（morning visits，average outpatient visits time，and visits in the past month）．Results　The blood pressure control rate before intervention in the study group was lower than that after intervention;the medical cost of chronic diseases in the past two weeks was higher than that after intervention;the satisfaction rates of chronic disease management and contracting service was lower than those after intervention.The morning visiting rate，outpatient visiting time and visits in the past month in the study group were higher than those after intervention（P<0.05）．The satisfaction rates of chronic disease management and contracting service in the control group before intervention were lower than those after intervention（P<0.05）．After intervention，blood pressure control rate in the study group was higher than that in the control group，and the morning visiting rate and the average outpatient visits in the study group were lower than those in the control group（P<0.05）．Conclusion　The community chronic diseases active reservation health management model for chronic diseases can improve blood pressure control rate, patient satisfaction and medical staff work efficiency, and shorten the average time of outpatient visits.

Key words: Chronic disease, Community health services, General practitioners, Appointments and schedules, Disease management

摘要： 背景　慢性病已经成为威胁中国人健康的头号疾病，其造成的死亡人数占每年1 030万死亡人数的80%。如果不加以控制，其治疗产生的直接成本和由于丧失劳动力、健康损失造成的经济成本会加重个人、企业政府的负担。目的　研究慢性病主动预约健康管理模式对原发性高血压病的管理效果，推进家庭医生签约工作。方法　2017年3月随机选取成都市武侯区晋阳社区卫生服务中心在管的450例签约原发性高血压病患者作为试验组；在武侯区其他家社区卫生服务中心采用分层抽样方法选取在管的签约原发性高血压病患者450例作为对照组。试验组针对不同病情分级分层患者制定相应主动预约健康管理干预方案，对照组按照《国家基本公共卫生服务规范（第三版）》高血压随访管理规范要求进行常规管理。干预期为2017年4月—2018年4月。采用自制的调查问卷通过前后及平行对照评估慢性病管理效果。调查问卷内容包括基本资料（性别、年龄、医保、文化程度、病程、并发症）、慢性病管理质量（血压控制率、慢性病近两周医疗费用）、患者满意度和医务人员工作效率（患者上午时段就诊率、门诊接诊平均耗时、近1个月内患者就诊次数）。结果　试验组干预前血压控制率低于干预后，慢性病近两周医疗费用高于干预后，慢性病管理服务满意度、签约服务满意度低于干预后，患者上午时段就诊率、门诊接诊平均耗时及近1个月内患者就诊次数高于干预后（P<0.05）；对照组干预前慢性病管理满意度、签约服务满意度低于干预后（P<0.05）。干预后试验组血压控制率高于对照组，患者上午时段就诊率及门诊接诊平均耗时低于对照组（P<0.05）。结论　慢性病主动预约健康管理模式可提高血压控制率、患者满意度及医务人员工作效率，缩短门诊接诊平均耗时。

关键词: 慢性病, 社区卫生服务；全科医生, 病人预约和时间安排, 疾病管理