健康随访包系统在不同国家和地区的应用有哪些差异？

一、应用领域的差异

1、 Differences in application fields

糖尿病领域：在埃及，有研究通过电话随访和教育包来改善糖尿病患者的生活方式和临床状态。具体而言，该研究采用准实验设计，对 100 名年龄在 18 至 65 岁的糖尿病患者进行研究，使用患者评估表和健康促进生活方式档案等工具，结果显示电话随访教育后患者的生活方式和临床数据有显著差异，表明远程护理对糖尿病患者是一种有效的护理策略。在中国，有研究利用云随访平台对糖尿病患者进行健康教育，结果表明可有效提高糖尿病住院患者对健康教育内容的掌握，减少护理人员工作负荷，提高患者对护理的满意度。

Diabetes: In Egypt, there are studies to improve the lifestyle and clinical status of diabetes patients through telephone follow-up and education packages. Specifically, the study used a quasi experimental design to study 100 diabetes patients aged between 18 and 65 years. Using the patient assessment form and health promotion lifestyle files and other tools, the results showed that there were significant differences in the lifestyle and clinical data of patients after telephone follow-up education, indicating that remote nursing was an effective nursing strategy for diabetes patients. In China, some studies have used cloud follow-up platform to conduct health education for diabetes patients. The results show that it can effectively improve diabetes inpatients' mastery of health education content, reduce the workload of nursing staff, and improve patients' satisfaction with nursing.

减肥手术领域：瑞典的一项研究评估了智能手机远程随访在减肥手术后患者中的可行性。在该研究中，干预组患者通过智能手机应用程序接受随访，对照组在门诊进行每三个月一次的标准随访。结果显示，两组在体重减轻、并发症发生率、生物电阻抗分析参数和生活质量方面没有显著差异，但干预组的血清钙水平显著高于对照组。这表明智能手机应用程序的远程随访至少与门诊传统随访一样有效，并且可以为患者节省时间，让医疗专业人员有更多资源用于处理更严重问题的患者。

In the field of weight loss surgery, a Swedish study evaluated the feasibility of smartphone remote follow-up in patients after weight loss surgery. In this study, the intervention group received follow-up through a smartphone application, while the control group underwent standard follow-up every three months in the outpatient department. The results showed that there were no significant differences between the two groups in terms of weight loss, incidence of complications, bioelectrical impedance analysis parameters, and quality of life, but the intervention group had significantly higher serum calcium levels than the control group. This indicates that remote follow-up through smartphone applications is at least as effective as traditional outpatient follow-up, and can save patients time, allowing medical professionals to have more resources to deal with patients with more serious problems.

慢性肾脏病领域：在中国，基于慢性病管理模型构建智能健康随访管理系统应用于慢性肾脏病患者。通过组建团队、搭建系统架构、建立专病数据库及开发应用模块，对患者进行随访。干预六个月后，观察组自我管理能力评分显著高于对照组，肌酐、尿微量白蛋白肌酐比值、收缩压、舒张压、BMI 值显著低于对照组，表明该系统能提高慢性肾脏病患者的自我管理能力，延缓疾病进展。

In the field of chronic kidney disease: In China, an intelligent health follow-up management system based on a chronic disease management model is applied to patients with chronic kidney disease. By forming a team, building a system architecture, establishing a specialized disease database, and developing application modules, patients are followed up. After six months of intervention, the self-management ability score of the observation group was significantly higher than that of the control group. The creatinine, urinary microalbumin creatinine ratio, systolic blood pressure, diastolic blood pressure, and BMI values were significantly lower than those of the control group, indicating that the system can improve the self-management ability of patients with chronic kidney disease and delay disease progression.

外周动脉疾病领域：巴西的研究开发了一款针对外周动脉疾病患者的移动教育随访应用程序。该应用程序的教学内容基于对患者需求的调查和文献推荐的治疗方法，包含概念、危险因素、症状、治疗、药物重要性及副作用、常见疑问、必要的医疗护理以及通过监测病变瘢痕过程和可能并发症的进展来进行随访等内容。结论认为该应用程序有潜力改善患者对疾病进展的随访和自我护理，监测危险因素，促进患者参与治疗和家庭参与，以及规划个性化护理并降低卫生系统成本。

In the field of peripheral arterial disease, Brazil has developed a mobile education follow-up application for patients with peripheral arterial disease. The teaching content of this application is based on a survey of patient needs and literature recommendations for treatment methods, including concepts, risk factors, symptoms, treatment, drug importance and side effects, common questions, necessary medical care, and follow-up through monitoring the progression of scar lesions and possible comorbidities. The conclusion is that this application has the potential to improve patients' follow-up and self-care of disease progression, monitor risk factors, promote patient participation in treatment and family involvement, as well as plan personalized care and reduce healthcare system costs.

二、随访方式的差异

2、 Differences in follow-up methods

电话随访：埃及在糖尿病患者的护理中采用电话随访的方式，结合教育包对患者进行干预，以评估其对患者生活方式和临床状态的影响。这种方式相对传统，但在一定程度上能够为患者提供及时的护理指导和信息支持。

Telephone follow-up: Egypt used telephone follow-up in the nursing of patients with diabetes, combined with the education package to intervene the patients, so as to assess their impact on their lifestyle and clinical status. This approach is relatively traditional, but to a certain extent, it can provide timely nursing guidance and information support for patients.

智能手机应用程序随访：瑞典在减肥手术后患者的随访中使用智能手机应用程序，巴西在外周动脉疾病患者的随访中也开发了移动教育随访应用程序。这种方式更加便捷高效，患者可以随时随地通过手机接收问卷和健康信息，医疗专业人员也可以更方便地对患者进行远程监测和管理。

Smartphone application follow-up: Sweden uses smartphone applications for follow-up of patients after weight loss surgery, and Brazil has also developed mobile education follow-up applications for follow-up of peripheral arterial disease patients. This method is more convenient and efficient, as patients can receive questionnaires and health information anytime and anywhere through their mobile phones. Medical professionals can also conveniently monitor and manage patients remotely.

智能健康随访管理系统随访：中国在慢性肾脏病患者的管理中构建了智能健康随访管理系统，通过组建团队、搭建系统架构等方式，为患者提供全面的随访服务。这种系统整合了多种资源，能够实现对患者的个性化管理和精准干预。

Intelligent Health Follow up Management System Follow up: China has built an intelligent health follow-up management system for the management of chronic kidney disease patients, providing comprehensive follow-up services to patients through team building, system architecture, and other methods. This system integrates multiple resources and can achieve personalized management and precise intervention for patients.

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