多病共存管理基层实践专家共识

中国老年保健协会数智健康保障分会

doi:10.16766/j.cnki.issn.1674-4152.004320

多病共存管理基层实践专家共识

doi: 10.16766/j.cnki.issn.1674-4152.004320

中国老年保健协会数智健康保障分会

基金项目:

国家科技重大专项项目 2023ZD0503600

国家科技重大专项项目 2023ZD0503606

河南省医学科技攻关计划软科学重点项目 RKX202401003

详细信息

中图分类号: R197.323.2 R592 R499
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- 文章访问数: 28
- HTML全文浏览量: 22
- PDF下载量: 18
- 被引次数: 0
出版历程
- 收稿日期: 2025-04-26
- 网络出版日期: 2026-04-01

Expert consensus on primary care practice for the management of multimorbidity

The Digital and Intelligent Health Security Branch of the China Association for Health Care of the Elderly

摘要

摘要: 随着我国慢性病患病率上升，多病共存已成为基层医疗面临的重大挑战。多病共存管理需面对疾病诊疗复杂性、治疗目标冲突、资源协调困难等诸多问题。为提升基层医疗机构对多病共存患者的综合管理能力，本共识由多学科专家组基于循证医学原则制定，提出了涵盖定义与评估、常见疾病簇、院内外评估路径、全科管理策略、家庭与自我管理、生活方式干预、随访与转诊、预防策略及终末期照护等内容的系统性指导意见。共识强调以患者为中心，倡导多学科协作、信息整合与连续性照护，旨在为基层医疗机构提供具有可操作性和适应性的实践指导框架，从而优化多病共存患者的健康结局和生活质量。
- 多病共存 /
- 健康管理 /
- 基层实践 /
- 专家共识
Abstract: With the acceleration of population aging and rising prevalence of chronic diseases in China, multimorbidity has emerged as a major challenge for primary healthcare. The management of patients with multimorbidity is characterized by substantial clinical complexity, potential treatment conflicts, and challenges in resource coordination. To enhance the comprehensive management capacity of primary healthcare institutions, this expert consensus was developed by a multidisciplinary panel in accordance with evidence-based principles. It provides systematic guidance across key domains, including the definition and assessment of multimorbidity, disease cluster typologies, hospital and community-based evaluation strategies, principles of general practice management, individualized care, family and self-management, lifestyle interventions, follow-up and referral procedures, prevention strategies, and end-of-life care. Emphasizing person-centered care, multidisciplinary collaboration, information integration, and continuity of care, this consensus aims to deliver practical and adaptable recommendations to primary care institutions, ultimately improving health outcomes and quality of life for patients with multimorbidity.
- Multimorbidity /
- Health management /
- Primary care practice /
- Expert consensus

HTML全文

图 1 多病共存基层管理流程

Figure 1. Primary care management pathway for multimorbidity

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表 1 多病共存与共病概念的区别

Table 1. Differences between multimorbidity and comorbidity concepts

对比维度	多病共存(multimorbidity)	共病(comorbidity)
定义	个体同时患有2种或以上的慢性疾病，不设主要疾病，所有疾病同等重要	在某一特定主要疾病的基础上，同时存在的其他疾病
疾病关系	多种疾病叠加存在，疾病之间可能存在相互作用，但不围绕某一主要疾病展开	附加疾病围绕主要疾病展开，关注其对主要疾病的影响
研究关注点	患者整体健康状况及其长期发展	某一特定疾病的并存情况及其影响
管理方式	整合式管理，个体化干预和多学科协作	以主要疾病为核心的单病种管理
健康影响	影响患者的生理、心理、功能状态及生活质量	主要影响特定疾病的诊疗策略及其预后
医疗模式	以人为中心的综合医疗模式，强调长期管理	以疾病为中心的医学模式，强调针对特定疾病的管理
适用领域	全科医学、老年医学、慢病管理、公共卫生	专科医学、慢性病研究

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表 2 4种多病共存疾病负担评估工具的区别

Table 2. Differences between four multimorbidity burden assessment tools

评估工具	核心原理	权重来源	主要用途	适用场景	局限性
ACG系统	基于疾病组合预测医疗资源消耗(马尔可夫链蒙特卡洛模拟)	ICD编码的疾病组资源利用频率(如糖尿病合并高血压权重系数为0.32)	成本预测、DRG分组、医保管理	基层医疗、慢性病管理	忽略疾病严重程度与交互作用
Charlson指数	整合17种疾病的死亡风险权重(广义估计方程校正)	NHANES Ⅲ队列研究确定的死亡风险倍数(如心肌梗死权重5.2，HR=5.2)	死亡风险分层、急诊危重症预后评估	急诊科、重症监护、长期随访	未涵盖非致命性疾病负担
CIRS-GO指数	多维健康状态评分(生理/心理/社会功能，Rasch模型构建)	Delphi法共识(专家权重)+患者自评量表(Cronbach's α=0.89)	功能状态评估、生活质量监测、肿瘤幸存者管理	慢性病管理、老年患者评估	计算复杂度高，需专业培训
Elixhauser指数	基于32种诊断条件的住院风险预测模型(逻辑回归分析)	住院并发症发生率(如肺炎权重2.1，ICU转入权重3.5)	住院并发症预测、长期照护风险评估	三级医院、术后康复管理	条目过多(32项诊断条件)

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