Development and effectiveness verification of personalized management plan for chronic diseases based on patient demand orientation
基于患者需求导向的慢病全科个性化管理方案的制定与效果验证

摘要

目的 制定基于患者需求导向的慢病全科个性化管理方案，验证其在慢病患者管理中的应用效果。方法 选取2024年7月—2025年7月本院全科门诊收治的60例慢病患者为研究对象，采用随机数字表法分为两组。对照组实施慢病全科常规管理，观察组实施基于患者需求导向的个性化管理方案。比较两组自我管理能力及不良事件。结果 干预6个月后，观察组CSMS量表用药管理、饮食管理、运动管理、病情监测、并发症管理评分均高于对照组；观察组不良事件发生率低于对照组（P＜0.05）。结论 基于患者需求导向的慢病全科个性化管理方案可有效提升慢病患者疾病控制效果，增强自我管理能力，降低不良事件发生风险，值得推广应用。

Abstract

Objective To develop a personalized management plan for chronic diseases based on patient needs and verify its application effect in the management of chronic disease patients.
Methods Sixty chronic disease patients admitted to the general outpatient department of our hospital from July 2024 to July 2025 were selected as the research subjects and randomly divided into two groups using a random number table method. The control group implemented routine management of chronic diseases, while the observation group implemented personalized management plans based on patient needs. Compare the self-management abilities and adverse events between two groups.
Results After 6 months of intervention, the CSMS scale scores for medication management, diet management, exercise management, disease monitoring, and complication management in the observation group were higher than those in the control group; The incidence of adverse events in the observation group was lower than that in the control group (P<0.05).
Conclusion   A personalized management plan for chronic diseases based on patient needs can effectively improve the disease control effect of chronic disease patients, enhance self-management ability, and reduce the risk of adverse events. It is worth promoting and applying.