社区多重慢病与健康管理

Multimorbidity in the community and its health care management

环境、人口、及经济转型带来的慢性非传染性疾病已经成为许多国家的头号健康威胁。多重病的患病率近年来稳步上升，与年龄增长密切相关，同时也与医疗服务因素及生活方式相关。多重慢病患者有更大的卫生保健需求。国际经验已经表明了初级卫生保健的巨大作用。加强初级保健下的社区健康管理可以带来更适宜、更有成效及更低成本的护理。面对来自于慢性疾病及多重病的新兴公共卫生问题，更需要加强多学科医疗保健服务模式下的社区健康管理。

As a result of the environmental, demographic, and economic transitions, non-communicable chronic diseases have become the number one health threat in many countries. The prevalence of coexistent multiple chronic conditions （multimorbidity） increases steadily at all ages, and this may be associated with a number of underlying healthcare and lifestyle factors. Patients with multimorbidity have greater health care needs. The contributions of primary care have been demonstrated globally. Strong primary care is associated with more appropriate, more effective, and less costly care. In rage of the emerging public health problems stemming from chronic diseases and multimorbidity, primary care-based multi-disciplinary health care models will need to be implemented.