国内外多重慢病健康服务整合研究进展

Research Progress of International and Domestic Integrated Health Care of Multimorbidity

随着疾病谱的逐渐转变,慢性非传染性疾病(以下简称慢病)已经严重威胁我国及全球健康和经济发展。慢病的致病因素多且病程长,患者常出现同时患有2种或2种以上慢病的累积状态,即多重慢病。多重慢病问题日益凸显且存在年轻化趋势,有效整合以疾病为中心、以治疗为根本的碎片化、非连续性的健康服务对解决该问题意义重大。本文梳理了国内外多重慢病健康服务整合的研究现状及发展动态,分析当前多重慢病的健康整合服务研究和实践中存在的不足,提出构建以多重慢病患者为中心的个性化整合服务模型及探索真实世界的多重慢病整合服务效果定量评价实践是未来多重慢病整合服务研究的发展方向,为我国高效、可持续的多重慢病服务整合机制的建立提供借鉴。

With the gradual shift in the disease spectrum,chronic non-communicable diseases(hereafter referred to as"chronic diseases")have become a serious threat to health and economic development in China and globally.Due to various pathogenic factors and a long course of disease,patients with chronic diseases often have a chronic disease accumulation state of individuals suffering from two or more chronic diseases at the same time,referred to as multimorbidity.The problem of multimorbidity is becoming increasingly prominent with a younger trend.The effective integration of fragmented and discontinuous health services,which are disease-centered and treatment-based,is of great significance in addressing this problem.This paper reviewed the current research status and development trends of multimorbidity health service integration at home and abroad,and analyzed the shortcomings of the current researches and practices of integrated health care of multimorbidity.It is proposed that constructing a personalized integrated service model centered on patients with multimorbidity and exploring the quantitative evaluation practice of integrated health care of multimorbidity in the real world are the development direction of future research on multimorbidity integrated services,providing reference for realizing the efficient and sustainable integration mechanism of multimorbidity services among medical institutions in China.