慢病是威胁人类健康的公共卫生问题，2025年国家卫健委数据显示：高血压/糖尿病知晓率分别提升至68.5%/58.3%，但基层控制达标率仍低于40%。西南地区村医缺口达23.7%，单名村医平均需管理189名慢病患者。还有包括高血压、糖尿病、脑卒中、冠心病压等，都属于高发病率、高病死率、高致残率和低知晓率、低控制率、低治疗率的常见慢病。

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，但在一些偏远的地方，村民本身不够重视，检查麻烦看病也难，加上医生的资源较缺乏，在综合因素的影响下，慢性病患病率呈上升趋势，患者基数也不断扩大。常规慢病管理主要靠患者自我检测，存在操作不规范、设备老化、遗忘测量、测量时间不规律、缺少长期记录等诸多问题，导致很难有效实现慢病管理。而到医院检查又需挂号，排队，费时费力，成本很高。所以不少慢病患者渐渐只能是“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.

近两年，随着国家对基层医疗的重视与投入，分级诊疗体系逐步建设深入，各大社区卫生服务中心正在逐步建立慢病管理制度，建立社区慢病防治网络，对社区高危人权和重点慢病定期筛查，掌握病患情况，建立信息档案库，同时对人群重点慢病分类监测、登记。不少地区的村医、家庭医生建立了慢病随访制度，定期上门诊疗，为健康促进和干预提供良好基础。

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.

慢病随访包，便携易用，为村医、家庭医生等打通慢病管理最初的百米，随时随地进行基础健康数据快速检测及收集，同时生成健康管理档案，让慢病患者都能享受到快捷的健康管理服务，提高医护人员工作效率。检测结果可上传至Medibase健康管理云平台，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

慢病随访包，具有无线数据传输功能，便于收集各项健康检测生理参数，生成健康评估报告并建立健康管理档案，集数据收集、健康分析、电子病历为一体，便于医护工作人员及时给慢病患者提供健康管理建议，有效协助院外慢病干预及慢病健康管理。

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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