探讨慢性病一体化门诊的慢病管理指数与老年衰弱的关联，旨在为基层开展老年衰弱早期防控提供依据。

以便利抽样法选取2025年6—12月纳入杭州市良渚街道慢性病一体化门诊管理的社区老年慢性病患者作为研究对象。采用现场调查法获取患者一般资料，Tilburg衰弱评估量表评估患者衰弱状态，同时提取患者的慢病管理指数。将单因素分析（Mann-Whitney U检验、χ²检验、Fisher确切概率法）有统计学意义的衰弱相关指标纳入多因素Logistic回归模型进一步分析。绘制受试者工作特征（ROC）曲线分析慢病管理指数对社区老年慢性病患者衰弱的诊断效能。

共入组社区老年慢性病患者161例，其中衰弱患者45例（衰弱组），非衰弱患者116例（非衰弱组）。两组患者性别、年龄、每周锻炼频次、慢性病种类、服药种类及慢病管理指数的差异均有统计学意义（P<0.05或0.01）。Logistic回归分析显示，调整性别、年龄、每周锻炼频次、慢病种类及服药种类后，慢病管理指数仍与衰弱存在负向关联（OR=0.845，95%CI：0.742~0.940，P<0.01）。ROC曲线分析显示，慢病管理指数区分衰弱与非衰弱的曲线下面积为0.759（95%CI：0.680~0.839），最佳截断值为81.25分，敏感度为84.4%，特异性为59.5%。

慢病管理指数与社区老年慢性病患者衰弱存在显著负向关联，基层医疗机构应重点关注慢病管理指数偏低的老年慢性病患者，及时开展衰弱专项评估与综合干预，以延缓其衰弱进程。

To explore the association between the chronic disease management index based on integrated chronic disease clinics and frailty in community-dwelling older patients with chronic diseases, so as to provide evidence for early prevention and control of frailty at primary healthcare institutions.

A convenience sampling method was used to recruit community-dwelling older patients with chronic diseases who were enrolled in the integrated chronic disease outpatient management program in Liangzhu Subdistrict, Hangzhou, from June to December 2025. A field survey was used to collect the patients’ general information, the Tilburg Frailty Indicator was used to assess their frailty status, and the patients’ chronic disease management index was extracted at the same time. Frailty-related indicators that were statistically significant in univariate analysis (Mann-Whitney U test, chi-square test, and Fisher's exact test) were included in a multivariable logistic regression model for further analysis. Receiver operating characteristic (ROC) curves were plotted to analyze the diagnostic performance of the chronic disease management index for frailty in community-dwelling older patients with chronic diseases.

A total of 161 community-dwelling older patients with chronic diseases were enrolled, including 45 frail patients (frailty group) and 116 non-frail patients (non-frailty group). There were statistically significant differences between the two groups in sex, age, weekly exercise frequency, types of chronic diseases, types of medications, and the chronic disease management index (P < 0.05 or P < 0.01). Logistic regression analysis showed that after adjusting for sex, age, weekly exercise frequency, types of chronic diseases, and types of medications, the chronic disease management index remained negatively associated with frailty (OR=0.845, 95%CI: 0.742-0.940, P < 0.01). ROC curve analysis showed that the area under the curve for the chronic disease management index in distinguishing frailty from non-frailty was 0.759 (95%CI: 0.680-0.839), with an optimal cutoff value of 81.25 points, a sensitivity of 84.4%, and a specificity of 59.5%.

The chronic disease management index is significantly negatively associated with frailty in community-dwelling older patients with chronic diseases. Primary healthcare institutions should pay close attention to older patients with chronic diseases who have low chronic disease management index scores, promptly conduct specialized frailty assessment and comprehensive intervention, and thereby delaying the progression of frailty.