ISSN 2097-5724 CN 61-1535/R 主管·主办:陕西省疾病预防控制中心
疾病预防与控制 Disease Prevention and Control 医学学术期刊 双月刊
2026-03-007 综述 2026, 2(03): 25-28

AI赋能社区老年人慢性病管理的模式比较与优化路径

广西医科大学

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摘要

随着人口老龄化加速,社区老年慢性病管理已成为公共健康治理的重点。传统模式以定期随访和被动干预为主,监测滞后、管理碎片化,难以满足多病共存、长期管理与持续监测的需求。人工智能(AI)技术为慢病管理提供了新的解决思路,通过智能监测设备、健康管理平台和智能随访系统,实现主动预警与持续干预。本文以三个案例为研究对象,发现AI在提升慢病监测实时性、促进信息共享、提高诊疗效率等方面效果显著,但仍存在适老化不足、数据孤岛、多主体协同治理缺失以及隐私安全风险等问题。为此,本文提出:推进系统适老化与数据融合,构建社区-医疗机构-平台企业的协同治理机制,强化数据安全与伦理监管,提高老年人数字健康素养与技术接受度。本研究为智慧社区健康管理模式提供了实践依据。

Abstract

With the acceleration of population aging, community-based chronic disease management has become a key focus in public health governance. Traditional models primarily rely on periodic follow-ups and passive interventions, resulting in delayed monitoring, fragmented management, and difficulties in meeting the needs of multimorbidity, longterm management, and continuous surveillance. Artificial intelligence(AI) technology offers new solutions for chronic disease management through intelligent monitoring devices, health management platforms, and smart follow-up systems, enabling proactive early warnings and sustained interventions. This study examines three case studies and finds that AI significantly improves real-time chronic disease monitoring, facilitates information sharing, and enhances diagnostic and treatment efficiency. However, challenges persist, including insufficient aging adaptability, data silos, a lack of multi-stakeholder collaborative governance, and privacy and security risks. To address these issues, this paper proposes: advancing system aging adaptability and data integration, establishing a collaborative governance mechanism involving communities, medical institutions, and platform enterprises, strengthening data security and ethical oversight, and improving older adults' digital health literacy and technology acceptance. This research provides a practical foundation for intelligent community health management models.

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[1]丁吉,张楠,王尧,等.AI赋能社区老年人慢性病管理的模式比较与优化路径[J].疾病预防与控制,2026,2(03):25-28.