With the acceleration of urbanization and aging, chronic diseases such as hypertension combined with diabetes bear a heavy burden, while community management faces challenges like unsystematic medication management and poor patient compliance, and existing medication therapy management (MTM) practices rely on large hospitals, are limited to in-hospital settings and lack standard paradigms suitable for primary care, so it is urgent to build a standardized and easy-to-implement home-based MTM service model.

To develop a home-based pharmaceutical care model adapted for primary care settings based on MTM principles, and to evaluate its implementation feasibility and preliminary clinical effects among community-dwelling patients with hypertension and diabetes comorbidity.

A prospective randomized-controlled study was conducted. A total of 168 contracted patients with comorbid hypertension and diabetes were recruited from March to April 2024 from a community health center in Xuzhou. Among them, 18 patients were excluded for failing to meet the inclusion criteria, and 6 were excluded due to refusal to participate or inability to complete follow-up. Finally, 144 patients were included in the study. The patients were randomly assigned in a 1∶1 ratio to an intervention group (n=72) or a control group (n=72) using a computer-generated random sequence. The intervention group received a 6-month home-based MTM pharmaceutical care intervention, including comprehensive medication assessment and reconciliation, multidisciplinary collaborative intervention, and standardized monitoring and follow-up using simple tools (paper logbooks, WeChat groups). The control group received routine follow-up management for 6 months. Differences in medication adherence, disease control rates, safety, and direct medical costs were compared. Feasibility indicators such as recruitment rate and intervention completion rate were also assessed.

After the intervention, the medication adherence score in the intervention group was higher than that in the control group (P<0.05); systolic blood pressure, diastolic blood pressure, and HbA_1c levels were lower than those in the control group (P<0.05); and the control rates of blood pressure and HbA_1c were higher than those in the control group (P<0.05). There was no statistically significant difference in the incidence of adverse drug reactions (ADR) between the two groups (P>0.05). The per capita direct medical cost in the intervention group was lower than that in the control group (P<0.05). The recruitment rate was 85.7% (144/168), the intervention completion rate was 94.4% (68/72), and the service acceptability score was (4.3±0.7).

The home-based MTM pharmaceutical care model developed in this study was generally feasible and well accepted in primary care settings, and showed potential in improving medication adherence, disease control, and medication safety. Its clear workflow and simple tools provide a referable pathway for standardized pharmaceutical care for chronic diseases in primary care.

随着城镇化和老龄化加快，高血压合并糖尿病等慢性病负担重且社区管理存在药物管理不系统、患者依从性差等问题，现有药物治疗管理（MTM）实践依赖大医院、局限院内且缺乏基层适配的标准范式，亟须构建规范且易实施的居家MTM药学服务模式。

构建一种适用于基层的居家MTM药学服务模式，评估其在社区高血压合并糖尿病患者中实施的可行性，并初步观察其临床效果。

采用前瞻性随机对照研究，于2024年3—4月选取徐州市某社区卫生服务中心签约家庭医生服务的高血压合并糖尿病患者168例，其中因未满足纳入标准排除18例，因拒绝参与或无法完成随访排除6例，最终纳入144例。采用计算机生成的随机数字序列，将患者按1∶1比例分为干预组（n=72）和对照组（n=72）。干预组接受为期6个月的居家MTM药学服务，包括药物综合评估与重整、多学科协同干预及基于简易工具（纸质记录本、微信群）的标准化监测与随访。对照组接受同期6个月常规随访管理。比较两组干预前后的用药依从性、疾病控制率、安全性及直接医疗成本，并评估招募率、干预完成率等可行性指标。

干预后，干预组用药依从性评分高于对照组（P<0.05），收缩压、舒张压、糖化血红蛋白（HbA_1c）水平均低于对照组（P<0.05），血压达标率、HbA_1c达标率均高于对照组（P<0.05）。两组不良反应（ADR）发生率比较，差异无统计学意义（P>0.05）。干预组人均直接医疗成本低于对照组（P<0.05）。本研究招募率为85.7%（144/168），干预措施执行率（即完成全部6次随访的患者比例）为94.4%（68/72），服务接受度评分为（4.3±0.7）分。

本研究构建的居家MTM药学服务模式在基层展现出良好的可行性与可接受性，并初步显示出可改善患者用药依从性、提高疾病控制水平和用药安全性的潜力。该模式流程清晰、工具简便，为基层慢性病药学服务提供了可参考的路径。