家庭医生团队管理社区高血压、糖尿病的成效与启示

Objective To explore the application effect of the family doctor team management model in patients with primary hypertension and type 2 diabetes in the community. Methods The study subjects were chronic disease patients managed by the Community Health Service Center of Daxicheng Street in Kaili City from January 2022 to December 2025. The entire management area of Daxicheng Community was divided into 6 communities(Harmony Community, City Government Community, Nanshan Community, Yongle Community, Apple Mountain Community, and Jinshan Community) to form family doctor teams. The changes in indicators such as the number of patients included in management, the rate of standardized management, and the control rates of blood pressure and blood sugar were analyzed from 2022 to 2025. Results From 2022 to 2025, the number of patients willing to be included in chronic disease management increased year by year. The number of patients with hypertension under management rose from 4,367 in 2022 to 7,481 in 2025, while the number of patients with type 2 diabetes under management increased from 1,869 in 2022 to 3,144 in 2025. The average annual blood pressure control rate for hypertension was 87.36%, and the average annual blood glucose control rate for type 2 diabetes was 87.20%. In 2025, the blood pressure control rate for the managed hypertension population reached 92.70%, and the blood glucose control rate for the managed type 2 diabetes population reached 91.83%. The overall management effectiveness was remarkable. Conclusion The family doctor team management model can effectively increase the inclusion rate of community chronic disease patients and the control rate of indicators, meeting the requirements of the integration of medical and prevention, and has the value of promotion and implementation.