Volume 22 Issue 11
Nov.  2024
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Article Navigation >  Chinese Journal of General Practice  > 2024  >  22(11): 1899-1903
ZHOU Yingda, JIN Hua, YU Hao, CHEN Chen, QIU Baohua, SHI Ling, YU Dehua. Analysis of chronic disease management implementation in community health service center in Shanghai[J]. Chinese Journal of General Practice, 2024, 22(11): 1899-1903. doi: 10.16766/j.cnki.issn.1674-4152.003760
Citation: ZHOU Yingda, JIN Hua, YU Hao, CHEN Chen, QIU Baohua, SHI Ling, YU Dehua. Analysis of chronic disease management implementation in community health service center in Shanghai[J]. Chinese Journal of General Practice, 2024, 22(11): 1899-1903. doi: 10.16766/j.cnki.issn.1674-4152.003760
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Analysis of chronic disease management implementation in community health service center in Shanghai

doi: 10.16766/j.cnki.issn.1674-4152.003760
  • 1.

    The Community Health Service Center of Zhenru Town, Putuo District, Shanghai 200333, China

Funds:

 72104183

 YDH-20170627

 Ye2202103

  • Received Date: 2024-06-12
    Available Online: 2024-12-31
    Abstract
  •   Objective  To investigate the overall implementation of chronic disease management in community health centers in Shanghai, and to assess and improve the current status of chronic disease management in community health centers in Shanghai.  Methods  In July 2022, a total of 247 community health centers in Shanghai were selected for analysis. A descriptive analysis was conducted on data related to chronic disease management, including objective quality control data and subjective questionnaire surveys, sourced from the Shanghai Clinical Quality Control Center of Family Medicine.  Results  A total of 238 community health centers participated in the study, 96.2%(229 centers) had established clear assessment criteria for chronic disease management, primarily focusing on patient satisfaction, health literacy questionnaire completion rates, and patient return visit rates. In the study, 98.3% of the 234 social health centers had a chronic disease management system, but only 67.2% of them regularly update their data, and 29.8% of them had incomplete information records. Taking hypertension management as an example, 90.7% of centers maintained standardized health records for patients, and follow-up visits were conducted in all communities. The current needs of social guards in implementing chronic disease management mainly include individualized management experiences, mobile management tools, risk assessment methods, and referral platforms. The main difficulties encountered in the implementation process included cumbersome information processing, inconsistent patient management, excessive time requirements, and complex assessment standards.  Conclusion  A community-centered chronic disease management model has been established, but attention is needed to address existing challenges. To enhance awareness and ability in chronic disease management, it is essential to optimize training and evaluation system of chronic disease management, accelerate the standardization of primary healthcare information, and strengthen supportive tools for chronic disease management within the community in multiple dimensions.

     

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    • References(17)
  • [1]
    国务院新闻办公室. 《中国居民营养与慢性病状况报告(2020年)》发布会[EB/OL]. (2020-12-24)[2024-02-16]. http://www.scio.gov.cn/gxjd/srbd/202207/t20220729_281849.html.

    The State Council lnformation Office. Conference on report on nutrition and chronic diseases of China residents (2020)[EB/OL]. (2020-12-24)[2024-02-16]. http://www.scio.gov.cn/gxjd/srbd/202207/t20220729_281849.html.
    [2]
    宋晓宇, 徐文妹, 陈静, 等. 慢性非传染性疾病管理模式研究进展[J]. 预防医学, 2019, 31(9): 901-905.

    SONG X Y, XU W M, CHEN J, et al. Research progress on chronic disease management[J]. China Preventive Medicine Journal, 2019, 31(9): 901-905.
    [3]
    朱璇, 陈爱云. 国外经典慢性病管理模式对我国慢性病管理的启示[J]. 中国全科医学, 2023, 26(1): 21-26.

    ZHU X, CHEN A Y. Enlightenment of foreign classical chronic disease management modes on the management of chronic diseases in China[J]. Chinese General Practice, 2023, 26(1): 21-26.
    [4]
    于德华. 全科医学思维引导下的科学研究构思[J]. 中国全科医学, 2023, 26(31): 3872-3876. doi: 10.12114/j.issn.1007-9572.2023.0053

    YU D H. Scientific research conception guided by general practice thinking[J]. Chinese General Practice, 2023, 26(31): 3872-3876. doi: 10.12114/j.issn.1007-9572.2023.0053
    [5]
    卢璇, 张建薇, 邓小岚, 等. 以专科护士为主导的老年慢病"互联网+护理服务"模式构建与实施[J]. 实用临床医药杂志, 2021, 25(9): 86-89, 93.

    LU X, ZHANG J W, DENG X L, et al. Establishment of"nursing assistance via the internet"mode for the elderly with chronic diseases dominated by specialist nurses and its implementation[J]. Journal of Clinical Medicine in Practice, 2021, 25(9): 86-89, 93.
    [6]
    李艳伟, 刘娜, 崔巍, 等. 慢病管理教学模式在全科住培中的应用研究[J]. 中国继续医学教育, 2021, 13(14): 80-84.

    LI Y W, LIU N, CUI W, et al. Study on the application of chronic diseasemanagement teaching mode in general living training[J]. China Continuing Medical Education, 2021, 13(14): 80-84.
    [7]
    郑艳玲, 余芳, 陈艳黎, 等. 我国全科医生职业倦怠状况及影响因素研究[J]. 中国全科医学, 2019, 22(7): 764-769.

    ZHENG Y L, YU F, CHEN Y L, et al. Prevalence and influencing factors for job burnout among general practitioners in China[J]. Chinese General Practice, 2019, 22(7): 764-769.
    [8]
    宣东平, 乔进, 赵彦, 等. 用药教育联合信息化随访对门诊2型糖尿病患者治疗效果的影响[J]. 实用临床医药杂志, 2021, 25(16): 81-84.

    XUAN D P, QIAO J, ZHAO Y, et al. Influence of medication education combined with information follow-up on therapeutic effect in patients with type 2 diabetes mellitus in clinic[J]. Journal of Clinical Medicine in Practice, 2021, 25(16): 81-84.
    [9]
    李臻, 石建伟, 陈宁, 等. 基于系统评阅的国内外慢性病管理模式问题分析与突破口评价[J]. 中国全科医学, 2020, 23(28): 3516-3521.

    LI Z, SHI J W, CHEN N, et al. The problem analysis and breakthroughs of domestic and overseas chronic disease management models based on the systematic review[J]. Chinese General Practice, 2020, 23(28): 3516-3521.
    [10]
    金花, 易春涛, 倪衡如, 等. 社区卫生服务中心全科医学临床质量状况及存在问题分析[J]. 中国全科医学, 2022, 25(1): 35-42.

    JIN H, YI C T, NI H R, et al. Quality of general medical care in community health centers in 2019—2020: overview and problems analysis[J]. Chinese General Practice, 2022, 25(1): 35-42.
    [11]
    张源, 凌涛, 范蒋青, 等. 我国分级诊疗政策背景下社区慢病管理实践分析[J]. 医药导报, 2023, 42(11): 1691-1696.

    ZHANG Y, LING T, FAN J Q, et al. Analysis of chronic disease management in the community under the background of hierarchical medical policy of China[J]. Herald of Medicine, 2023, 42(11): 1691-1696.
    [12]
    史威力, 王留义, 李明艳, 等. 基于慢病管理路径的社区高血压患者管理效果评价[J]. 中华全科医学, 2022, 20(11): 1893-1896. doi: 10.16766/j.cnki.issn.1674-4152.002729

    SHI W L, WANG L Y, LI M Y, et al. Effect evaluation of community hypertension patients' management based on chronic disease management pathway[J]. Chinese Journal of General Practice, 2022, 20(11): 1893-1896. doi: 10.16766/j.cnki.issn.1674-4152.002729
    [13]
    蒋伟萍, 陈远虹, 张晓芒, 等. 上海市杨浦区全科临床质量控制考核结果分析[J]. 中华全科医学, 2022, 20(6): 1000-1002, 1040. doi: 10.16766/j.cnki.issn.1674-4152.002509

    JIANG W P, CHEN Y H, ZHANG X M, et al. Analysis of assessment results of general practice clinical quality control in Yangpu District, Shanghai[J]. Chinese Journal of General Practice, 2022, 20(6): 1000-1002, 1040. doi: 10.16766/j.cnki.issn.1674-4152.002509
    [14]
    周英达, 瞿怡倩, 李笑飞, 等. 我国基层医疗诊断编码实施现况与优化策略[J]. 中国全科医学, 2024, 27(16): 1935-1941.

    ZHOU Y D, QU Y Q, LI X F, et al. Implementation status and optimization strategy of primary care diagnostic coding in China[J]. Chinese General Practice, 2024, 27(16): 1935-1941.
    [15]
    胡佳敏, 邱艳, 任菁菁. AI在基层医疗慢性病管理中的应用研究进展[J]. 中华全科医学, 2024, 22(3): 481-485. doi: 10.16766/j.cnki.issn.1674-4152.003431

    HU J M, QIU Y, REN J J. Advances in the application of AI in chronic disease management in primary care[J]. Chinese Journal of General Practice, 2024, 22(3): 481-485. doi: 10.16766/j.cnki.issn.1674-4152.003431
    [16]
    刘丰, 韩京龙, 齐骥, 等. 智能可穿戴设备的研究和应用进展[J]. 分析化学, 2021, 49(2): 159-171.

    LIU F, HAN J L, QI J, et al. Research and application progress of intelligent wearable devices[J]. Chinese Journal of Analytical Chemistry, 2021, 49(2): 159-171.
    [17]
    郑映微, 黄斌, 范冠华. 电子健康档案联合新媒介载体对社区居民健康促进效果的范围综述[J]. 中华全科医学, 2023, 21(6): 1048-1052. doi: 10.16766/j.cnki.issn.1674-4152.003046

    ZHENG Y W, HUANG B, FAN G H. Actual effect of electronic health records combined with new media carriers on health promotion of community residents: a scoping review[J]. Chinese Journal of General Practice, 2023, 21(6): 1048-1052. doi: 10.16766/j.cnki.issn.1674-4152.003046
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