上海市虹口区社区慢性病管理体系发展现状与困境质性研究

The status quo, problems and challenge of chronic disease management system in Shanghai Hongkou district

于2019年4—11月,对上海市虹口区5家社区卫生服务中心进行调研,以专题小组访谈方式采集各社区卫生服务中心慢性病管理实施方案及发展困境。根据调研结果,社区慢性病管理主要分为“成长期”(典型代表是高血压和糖尿病)和“引入期”(心脑血管疾病、呼吸系统疾病、老年痴呆、骨质疏松)两类。“成长期”慢性病管理,主要面临患者拒访或不配合、患者失访、质量控制不完善、质量控制指标难以达到、共病患者管理重复、信息共享不充分、多个考核方考核指标差异引发管理争议等困难;“引入期”慢性病管理,主要面临患者知晓率差、患者失访、诊断困难、用药不规范、信息共享不充分、缺乏管理方案、资源投入不足、社区药品种类少等困难。因此,社区需在注重积累慢性病管理经验的同时,及时进行提炼、总结和归纳,形成有效的方案用于指导对新增病种的管理;社区慢性病管理需要在社区居民动员、加速信息化网络建设、多中心协作研究等方面进一步努力。

From April to November 2019,5 community health service centers in Shanghai Hongkou District were randomly selected for thematic group interviews to investigate the current status,problems and challenge for further development of chronic disease management.The community chronic disease management was mainly divided into growth period(typically hypertension and diabetes)and introduction period(cardiovascular and cerebrovascular diseases,respiratory diseases,dementia,osteoporosis).The management of hypertension and diabetes in the growing stage mainly faced difficulties such as refusal or non-cooperation of patients,loss of follow-up,incomplete quality control,not meeting quality control indicators,repeated management of comorbidities,insufficient information sharing,and discrepancy in assessment indicators of multiple parties.The management of cardiovascular and cerebrovascular diseases,respiratory diseases and other diseases in the introduction period mainly faced poor awareness rate of patients,loss of follow-up,difficulty in diagnosis,irregular medication,insufficient information sharing,lack of management plan,insufficient resource investment,and few variety of medicines in the community.The current management system should be refined to provide more effective and efficient chronic disease management in the community.Meanwhile,the awareness of residents,the information network and multi-center collaborative research also need to be strengthened.