【摘要】 目的 构建社会支持视角下社区慢性病防控评价指标体系，并对不同管理模式进行回溯性效果评价。方法采用回顾性非随机整群对照设计，分析2022年1月-2023年1月某市两家社区120例高血压合并2型糖尿病患者资料，对比社会支持强化管理与常规管理效果，并运用该指标体系进行回溯性评分与中介效应分析。结果 最终形成3个一级指标、9个二级指标、28个三级指标。干预组组织保障、健康管理、社会动员评分均高于对照组(P<0.05);干预组自我管理能力评分、规律随访率、活动参与率均优于对照组(P<0.05),血压、血糖控制达标率更高，并发症发生率、急诊次数、再住院率更低，生命质量更高(P<0.05)。结论 经指标实证评分验证，社会支持强化管理可提升慢病控制效果，降低医疗资源利用，值得推广。更多还原

【Abstract】 Objective To construct an evaluation index system for community chronic disease prevention and control from the perspective of social support, and to conduct a retrospective effect evaluation on different management models.Methods A retrospective non-randomized cluster-controlled design was adopted to analyze the data of 120 patients with hypertension combined with type 2 diabetes mellitus from two communities in a certain city between January 2022 and January 2023.The effects of intensified social support management were compared with those of routine management.Furthermore, the established index system was applied for retrospective scoring and mediation effect analysis.Results The final evaluation index system consisted of 3 first-level indicators, 9 second-level indicators, and 28 third-level indicators.The intervention group achieved significantly higher scores than the control group in organizational guarantees, health management, and social mobilization(P<0.05).Moreover, the intervention group demonstrated superior self-management capability scores, regular follow-up rates, and activity participation rates compared to the control group(P<0.05).Additionally, the intervention group exhibited higher compliance rates for blood pressure and blood glucose control, along with lower incidence of complications, fewer emergency visits, reduced readmission rates, and improved quality of life(P<0.05).Conclusion Validated by empirical scoring using the index system, intensified social support management can enhance the effectiveness of chronic disease control and reduce the utilization of medical resources, making it worthy of widespread promotion.更多还原