Abstract:

Objective To construct a digital-intelligent proactive health management program for middle-aged and elderly patients with chronic kidney disease（CKD） and comorbidities and to evaluate its application effects, providing a reference for digital and intelligent proactive health management of middle-aged and elderly patients with CKD and comorbidities. Methods An intervention team was set up to build a digital-intelligent proactive health management program for patients with CKD and comorbidities. The research involved 176 middle-aged and elderly patients with CKD and comorbidities in a tertiary Grade A hospital in Zhejiang Province from November 2023 to April 2024. The patients were divided into an experimental group（n=88） and a control group（n=88） according to the random number table generated by SPSS. The experimental group implemented the digital-intelligent management system for proactive health management，while the control group received routine health management. Self-management ability，self-efficacy，physiological indicators and their compliance rates，and risk of renal failure were compared before the intervention，6 and 12 months after the intervention between the 2 groups. Results 83 cases in the experimental group and 84 cases in the control group reached the endpoint of the study after 12 months of intervention. The ANOVA of the 2 groups showed the experimental group having a greater advantage over the control group，with statistically significant differences in self-management ability，self-efficacy and physiological indicators between groups，time effect，and interaction effect（P<0.05）. After 12 months of intervention，the experimental group demonstrated significantly better outcomes than the control group in compliance rates of various physiological indicators（P<0.05）. Moreover，the experimental group exhibited significantly lower risks of renal failure at both 2-year and 5-year follow-ups（P<0.05）. Conclusion The digital-intelligent proactive health management program for middle-aged and elderly patients with CKD and comorbidities can enhance self-management ability and self-efficacy，improve physiological indicators，and reduce the risk of renal failure.

Key words: Middle-Aged and Elderly, Chronic Disease Comorbidity, Digital Intelligence, Proactive Health, Health Management, Nursing Care

摘要：

目的 构建中老年慢性肾脏病共病患者数智化主动健康管理方案，并评价其应用效果，为中老年慢性肾脏病共病患者数智化主动健康管理提供参考。 方法 构建中老年慢性肾脏病共病患者数智化主动健康管理方案。选取2023年11月—2024年4月在浙江省某三级甲等医院就诊的176例中老年慢性肾脏病共病患者作为研究对象，按照随机数字表法将患者分为试验组（n=88）和对照组（n=88），试验组应用数智化主动健康管理方案进行干预，对照组应用常规健康管理进行干预。比较两组在干预前、干预后6、12个月的自我管理能力、自我效能、生理指标及其达标率、干预前后肾衰竭风险的差异。 结果 干预12个月，最终试验组83例，对照组84例完成研究。重复测量方差分析结果显示，不同时间点两组自我管理能力、自我效能及生理指标的时间效应、交互效应均具有统计学意义（P<0.05），且试验组优于对照组；干预12个月后试验组的生理指标达标率均优于对照组，2年及5年肾衰风险均低于对照组，差异具有统计学意义（P<0.05）。 结论 中老年慢性肾脏病共病患者数智化主动健康管理方案可提高患者的自我管理能力及自我效能，改善患者生理指标，降低患者肾衰竭的风险。

关键词: 中老年, 慢性病共病, 数智化, 主动健康, 健康管理, 护理