我国基于团队协作的社区慢性病管理研究的分析

A brief review of research on chronic disease management based on collaborative care model in China

目的:了解我国慢性病管理实施现状,探索团队协作管理社区慢性病的改进方法。方法:利用关键词检索中国学术期刊网全文数据库、PubMed等常用中英文数据库,收集2008年1月至2013年12月公开发表的我国社区慢性病管理的研究报道,结合一定的纳入和排除标准,进行严格文献筛选;并基于慢性病团队协作管理模式对最后得出的文献进行归纳分析。结果:经系统检索后共得到698篇文献,进一步筛选得到33篇符合纳入标准的文献。在基于慢性病团队协作管理模式的几大要素中,全部文献涉及对慢性病患者的自我管理支持,但仅9篇提及团队成员之间的交流,11篇文献提及有明确的团队分工。结论:我国的社区慢性病管理工作存在不足,应建立一支真正意义上的全科服务团队,明确团队成员的角色与职责,提高团队成员的服务能力,同时应注意为患者提供多种形式的自我管理支持服务。

Objective: To evaluate the situation for chronic disease management in China, and to seek the method for improving the collaborative management for chronic diseases in community. Methods: We searched literature between January 2008 and November 2013 from the Database, such as China Academic Journal Full-Text Database, and PubMed. The screening was strictly in accordance with the inclusion and exclusion criteria and a summary was made among the selected literature based on a collaboration model. Results: We got 698 articles atfer rough screen and ifnally selected 33. All studies were involved in patient’s self-management support, but only 9 studies mentioned the communication within the team, and 11 showed a clear team division of labor. Conclusion: Chronic disease community management in China displays some disadvantages. It really needs a general service team with clear roles and responsibilities for team members to improve the service ability of team members and provide patients with various forms of self-management services.