慢性病管理的国际经验及启示
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篇名: 慢性病管理的国际经验及启示
TITLE:
摘要: 目的:为我国慢性病的综合干预和管理提供借鉴。方法:概括全球慢性病的流行趋势和疾病负担情况,总结分析国际社会慢性病管理的理论框架、实践内容和经验,以及对国内慢性病管理的启示。结果与结论:世界范围内比较有代表性的慢性病管理理论模型主要为美国的慢性病护理模型和世界卫生组织创新性慢性病管理框架。国际社会慢性病管理的主要经验为基于社区进行管理,明确优先干预的病种、采用规范化的临床诊疗路径、设计合理的转诊系统,以及提供患者自我管理支持。目前,我国在慢性病的控制方面已有改善,然而就社区层面来说仍显薄弱,需要加强社区医务人员慢性病防治知识培训及全人群的健康教育。
ABSTRACT: OBJECTIVE: To provide reference for comprehensive intervention and management of chronic disease in China. METHODS: The global chronic disease trends and disease burden were summarized; theoretical framework, practice and experience of international chronic disease management were summarized and analyzed as well as enlightenment on domestic chronic disease management. RESULTS&CONCLUSIONS: Worldwide prepresentative chronic disease theory model mainly involved USA chronic disease nursing model and WHO innovation care for chronic conditions. Main experience of international chronic disease management is that managing based on community, confirming preferential intervened disease types, adopting standardized clinical diagnosis and treatment pathway, designing rational transfer treatment system, providing patient self-management support. At present, chronic disease management have been improved in China, but is still poor in community management. It is necessary to strengthen community medical staff training about chronic disease prevention and treatment and health education for social group.
期刊: 2017年第28卷第8期
作者: 冯晶晶,刘宇飞,靖瑞锋
AUTHORS: FENG Jingjing,LIU Yufei,JING Ruifeng
关键字: 慢性病;健康管理;疾病负担;国际经验;慢性病护理模型;创新性慢性病管理框架;社区
KEYWORDS: Chronic disease; Health management; Disease burden; International experience; Chronic disease nursing model; Innovation care for chronic conditions; Community
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