中国全科医学2025，Vol.28Issue(31)：3897-3903,7.DOI:10.12114/j.issn.1007-9572.2025.0092
基本公共卫生服务下数字化赋能全-专协同社区慢性病路径化管理:实践探索与初步成效
Digitally Enabled Generalist-Specialist Collaborative Care on Chronic Care Management of Community under the National Basic Public Health Service:Practical Exploration and Early Achievement
摘要
Abstract
The advancement of high-quality national basic public health services continues to faces critical challenges,including insufficient quality resources in primary care and limited diagnostic and treatment capabilities.Since January 2022,Longhua District,Shenzhen initiated a pilot of the digitally enabled generalist-specialist collaborative care,aiming to enhance the capacity of primary healthcare service in managing hypertension and diabetes.This initiative leveraged the national basic public health services platform and the integration of medicine and prevention.Through policy guidance,system development,and digital support,the model sought to facilitate the efficient distribution and utilization of quality medical resources.This study presented the practical experiences of implementing the model from three key dimensions:policy mechanisms,practical measures,and early achievement.The preliminary practical achievements included:(1)Patient monitoring and enrollment:from 2022 to 2024,the proportion of hypertensive patients enrolled due to two consecutive instances of poor blood pressure control within six months was 35.3%,37.5%,and 36.2%,respectively;the proportion of diabetic patients enrolled due to two consecutive instances of poor blood glucose control within six months was 55.5%,64.0%,and 47.5%,respectively.(2)Specialist consultation:the timely consultation rates for hypertension and diabetes increased by 46.3%and 53.9%,respectively,in 2024,as compared to 2022,following the inclusion of the timely consultation rate in the performance evaluation of the medical consortium at the end of 2023.(3)Implementation by general practitioners:from 2022 to 2024,the timely implementation rate for hypertension increased from 73.7%to 84.3%,and for diabetes,from 73.9%to 80.8%.(4)Outcomes of patients managed by general practitioners and specialists:the average control rates during 2022 and 2024 for enrolled patients with hypertension and diabetes were 57.1%and 50.9%,respectively.The pilot experiences indicated that the digitally enabled generalist-specialist collaborative care effectively improved the management capacity of hypertensive and diabetic patients in primary care settings,contributing to better patient outcomes.At this critical juncture in advancing the high-quality development of national basic public health services,it was essential to establish implementation standards,strengthen supporting policy mechanisms and implementation strategies,and optimize the assessment and evaluation framework for basic public health services.These steps were vital to ensuring the successful nationwide adoption of this innovative policy model.关键词
公共卫生/国家基本公共卫生服务/基层慢性病健康管理/全-专协同/数字化/实践成效Key words
Public health/National essential public health services programs/Chronic disease management in primary care/General practice-specialty collaborative care/Digital/Implementation achievement分类
医药卫生引用本文复制引用
严新凤,刘刚,韩昕昕,于传宁,曹思静,殷道根,单晓桃,王奕婧,谢珮,赵洁,杨潍屹..基本公共卫生服务下数字化赋能全-专协同社区慢性病路径化管理:实践探索与初步成效[J].中国全科医学,2025,28(31):3897-3903,7.基金项目
国家自然科学基金资助项目(72404116) （72404116）
