慢病是威脅人類健康的公共衛生問題，2025年國家衛健委數據顯示：高血壓/糖尿病知曉率分別提升至68.5%/58.3%，但基層控制達標率仍低于40%。西南地區村醫缺口達23.7%，單名村醫平均需管理189名慢病患者。還有包括高血壓、糖尿病、腦卒中、冠心病壓等，都屬于高發病率、高病死率、高致殘率和低知曉率、低控制率、低治療率的常見慢病。

Chronic disease is a public health problem threatening human health. Data from the National Health Commission in 2025 show that the awareness rate of hypertension/diabetes has increased to 68.5%/58.3% respectively, but the compliance rate of grassroots control is still lower than 40%. The shortage of village doctors in the southwest region reaches 23.7%, with an average of 189 chronic disease patients to be managed by a single village doctor. There are also hypertension, diabetes, stroke, coronary heart disease pressure, etc., which are common chronic diseases with high incidence rate, high mortality, high disability rate, low awareness rate, low control rate, and low treatment rate.

慢病管理防大于治，但在一些偏遠的地方，村民本身不夠重視，檢查麻煩看病也難，加上醫生的資源較缺乏，在綜合因素的影響下，慢性病患病率呈上升趨勢，患者基數也不斷擴大。常規慢病管理主要靠患者自我檢測，存在操作不規范、設備老化、遺忘測量、測量時間不規律、缺少長期記錄等諸多問題，導致很難有效實現慢病管理。而到醫院檢查又需掛號，排隊，費時費力，成本很高。所以不少慢病患者漸漸只能是“慢病不管”了。

Prevention is more important than cure in chronic disease management, but in some remote areas, villagers themselves do not pay enough attention to it, and it is difficult to get checked and treated. In addition, the resources of doctors are relatively scarce. Under the influence of comprehensive factors, the incidence of chronic diseases is on the rise, and the number of patients is constantly expanding. Conventional chronic disease management mainly relies on patient self testing, which has many problems such as non-standard operation, aging equipment, forgotten measurements, irregular measurement times, and lack of long-term records, making it difficult to effectively achieve chronic disease management. And going to the hospital for examination requires registration, queuing, time-consuming and labor-intensive, with high costs. So many chronic disease patients can only gradually ignore chronic diseases.

近兩年，隨著國家對基層醫療的重視與投入，分級診療體系逐步建設深入，各大社區衛生服務中心正在逐步建立慢病管理制度，建立社區慢病防治網絡，對社區高危人權和重點慢病定期篩查，掌握病患情況，建立信息檔案庫，同時對人群重點慢病分類監測、登記。不少地區的村醫、家庭醫生建立了慢病隨訪制度，定期上門診療，為健康促進和干預提供良好基礎。

In the past two years, with the increasing attention and investment of the country in primary healthcare, the construction of a hierarchical diagnosis and treatment system has gradually deepened. Major community health service centers are gradually establishing chronic disease management systems, establishing community chronic disease prevention and control networks, regularly screening high-risk human rights and key chronic diseases in the community, grasping the situation of patients, establishing information archives, and classifying and monitoring key chronic diseases in the population. Many village doctors and family doctors in various regions have established a chronic disease follow-up system, providing regular home visits for diagnosis and treatment, and laying a solid foundation for health promotion and intervention.

慢病隨訪包，便攜易用，為村醫、家庭醫生等打通慢病管理最初的百米，隨時隨地進行基礎健康數據快速檢測及收集，同時生成健康管理檔案，讓慢病患者都能享受到快捷的健康管理服務，提高醫護人員工作效率。檢測結果可上傳至Medibase健康管理云平臺，便于慢病管理及院外管控。

The chronic disease follow-up kit is portable and easy to use, providing village doctors, family doctors, and others with access to the first hundred meters of chronic disease management. It allows for quick detection and collection of basic health data anytime, anywhere, and generates health management records, enabling chronic disease patients to enjoy fast health management services and improving the work efficiency of medical staff. The test results can be uploaded to the Medibase Health Management Cloud platform for easy management of chronic diseases and external control.

有效助力慢病管理

Effectively assist in chronic disease management

慢病隨訪包，具有無線數據傳輸功能，便于收集各項健康檢測生理參數，生成健康評估報告并建立健康管理檔案，集數據收集、健康分析、電子病歷為一體，便于醫護工作人員及時給慢病患者提供健康管理建議，有效協助院外慢病干預及慢病健康管理。

The chronic disease follow-up package has wireless data transmission function, which facilitates the collection of various health monitoring physiological parameters, generates health assessment reports, and establishes health management files. It integrates data collection, health analysis, and electronic medical records, making it easy for medical staff to provide timely health management advice to chronic disease patients and effectively assist in outpatient chronic disease intervention and chronic disease health management.

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