Expert consensus on the whole-course management in patients with arteriosclerotic cardiovascular disease in county-level medical consortium(2025)
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摘要: 由于人口老龄化加速以及心血管危险因素流行，我国心血管疾病的发病率和患病率均持续上升。心血管疾病位居我国城乡居民的首位死因，动脉粥样硬化性心血管疾病(ASCVD)带来的疾病负担逐渐加重。县域地区ASCVD面临着发病率高而管理率低的双重挑战，特别是农村地区的心血管死亡率持续超过城市。推进县域医共体建设是提升基层医疗卫生服务能力，优化医疗资源配置，促进医院高质量发展的关键举措。为帮助县域医共体单位建立ASCVD全病程管理体系，提高县域ASCVD服务能力和管理效率，提高医疗服务的连续性，改善患者就医体验，由中国健康促进与教育协会县域慢病健康管理分会、清华大学健康中国研究院和温州医科大学县域慢病健康管理研究院依据当前的临床医学证据，结合临床实践经验和创新管理实践，对县域医共体ASCVD全病程管理体系的12个关键问题给出了建议。本共识内容包括服务场地规划、软硬件设施配置、服务流程和标准建立、服务人员配置、服务内容设计、服务人员能力要求和培训提升以及服务质量控制和效率管理。共识重点突出管理体系建设的价值，以科学性为前提，侧重实践指导，有助于进一步促进上下联动、全专融合的分级诊疗模式推进，提高县域ASCVD的管理能力和管理效率，提高医疗服务的连续性。
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关键词:
- 全病程管理 /
- 心血管疾病 /
- 动脉粥样硬化性心血管疾病 /
- 县域医共体
Abstract: With accelerated population aging and widespread arteriosclerotic cardiovascular risk factors, the incidence and prevalence of cardiovascular diseases in China have continued to rise. Cardiovascular diseases remain the leading cause of death among urban and rural residents in China, with the economic burden of atherosclerotic cardiovascular disease (ASCVD) increasing steadily. The ASCVD in the county area is faced with the dual challenge of high incidence rate and low management rate, and cardiovascular mortality rate in rural areas consistently exceeds that in urban areas. Promoting the construction of county-level medical communities is a key strategy to enhance the primary healthcare capacity, optimize the allocation of medical resources, and promote high-quality development of hospitals. In order to help the county-level medical consortium to establish a comprehensive cardiovascular disease whole-course management system, enhance service capacity and management efficiency for ASCVD in county areas, improve continuity of medical services, and improve patients medical experience, the County Chronic Disease Health Management Branch of China Health Promotion and Education Association, Institute for Healthy China of Tsinghua University, and The County Chronic Disease Health Management Institute of Wenzhou Medical University formulated expert recommendations based on the current clinical evidence, clinical practical experience and innovative management practice. This consensus addresses 12 key issues related to the whole-course management system of ASCVD within county-level medical consortium. This consensus includes service venue planning, configuration of software and hardware, establishment of service processes and standards, staffing allocation, design of service content, requirements and training for service personnel' s capabilities, and quality and efficiency management of services. The consensus highlights the value of management system construction, emphasizes practical guidance based on scientific principles, promoting the hierarchical diagnosis and treatment model featuring top-down linkage, integrating general and specialized services, and enhancing the management capabilities and continuity of ASCVD services at the county level. -
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