摘要
研究目的
慢性非传染性疾病具有发病率高、致残率高和和死亡率高的特点。随着经济的发展,人们生活水平的提高,慢性病人出现日益增多的趋势。2005年中国居民营养与健康状况调查报告表明,我国成年高血压患病人数已超过1.6亿人。慢性病给国家、社会、家庭和个人带来了沉重的疾病经济负担,亟待探究价格低廉、效果好的慢性病管理模式。
本研究通过全面系统了解成都市高血压糖尿病患者社区卫生服务利用情况、疾病控制情况、慢性病管理运行情况,总结经验,发现问题,为进一步完善慢性病管理模式提供依据。
研究方法
本课题主要采用文献研究、现场调查、深入访谈、比较研究方法对成都市社区慢性病管理进行了调查分析。采用文献研究法总结出成都市社区慢性病管理特色,采用描述性分析法分析了高血压糖尿病患者社区卫生服务利用情况、控制情况、知信行情况；采用卡方检验和logistic多元回归分析法分析了患者利用和疾病控制的影响因素；采用主成分分析法和聚类分析法评价了高血压糖尿病患者对社区卫生服务的满意度。
研究结果
本课题研究结果主要包括以下几个方面：1.成都市社区慢性病建立档案率、规范管理率和管理模式。2006年成都市社区高血压糖尿病患者建档率28.57%,某区的高血压、糖尿病患者规范管理率55.03%、54.22%。成都市形成了分级管理和契约式管理相结合的慢性病管理模式。
2.成都市社区高血压糖尿病的疾病控制,利用情况。①人口学特征：调查对象2028人,高血压病人1716例,糖尿病病人590例,既有高血压又有糖尿病的病人278例；其中男性827人(40.5%),女性1207人(59.5%);年龄最大97岁,最小14岁,平均67.10±10.34岁。②利用情况：高血压糖尿病患者利用社区卫生服务监测治疗疾病的比率分别为81.41%、56.95%,监测频率分为一周,一周至两周,两周至一个月,一个月以上四个层次。高血压、糖尿病患者两周至一月监测的频率最高,分别为44.8%、47.5%,高血压患者需要缩短监测周期。③知晓情况：高血压、糖尿病患者一旦药物治疗需要终身服药的知晓率分别为90.0%、86.9%；血压正常值知晓率为79.4%,血糖正常值知晓率79.2%,但正确知晓率分别为48.9%、35.4%,患糖尿病的症状知晓率50.7%,说明基础知识的健康教育工作有待细致深入。④高血压、糖尿病患者服药依从性：按照医嘱服药的比率分别为94.7%、95.1%,规律服药的比率分别为90.9%、94.2%,依从性较好。⑤行为改变情况：患者在社区监测后,高血压患者控制情绪的比率是78.0%,加强锻炼的是76.7%,生活规律的比率是93.0%；糖尿病患者严格控制饮食的比率是57.1%,运动量增加的比率是62.1%。⑥建立健康档案和随访：在调查的2028例慢性病患者中,1819人明确自己是被社区卫生服务机构建立了健康档案,占89.7%；1829接受了全科医生的随访,占90.2%,随访分为门诊随访、入户随访和集体随访,比率分别为70.7%、27.0%、2.3%。⑦控制情况：高血压患者糖尿病患者的控制率分别为76.2、62.5%。
3.高血压糖尿病患者社区卫生服务满意度。满意度各要素评分中,服务态度平均分最高(4.45),技术水平平均分最低(4.00)。2066名就诊者对医疗机构满意度的总体评价中,0.1%的就诊者表示“很不满意”或“不满意”。主成分分析结果表明,有4个主因子；聚类分析结果表明,总体满意度、医疗费用、技术水平、出诊时服务态度为一组,就诊手续、慢性病防治讲解主动性为一组,就诊环境、就诊时服务态度看似可以单独为一组,但是又可以划入就诊手续、慢性病防治讲解主动性这一组。
4.高血压糖尿病患者利用社区卫生服务机构影响因素的logistic回归分析。影响高血压患者利用社区卫生服务的主要因素,年龄50-69岁、全部自费、城镇居民医疗保险、知晓免费血压测量点、终身服药的原则、建立了健康档案、接受了定期随访是影响高血压患者利用社区卫生服务的保护因素,不知晓血压正常值是影响高血压患者利用社区卫生服务的危险因素。全部自费、城镇居民医疗保险、终身服药的原则、按照医嘱服药、建立了健康档案、入户随访和门诊随访是影响糖尿病患者利用社区卫生服务的保护因素,不知晓血糖正常值是影响糖尿病患者利用社区卫生服务的危险因素。
5.高血压糖尿病控制率影响因素的logistic回归分析。知道血压测量点、知晓慢性病药物治疗需要终身服药、规律服药、加强锻炼、入户随访和门诊随访是高血压控制率的支持因素,个体经营者、城镇职工基本医疗保险、城镇居民基本医疗保险、新型农村合作医疗是高血压控制率的不利因素。一般职员／工人／服务员、按照医嘱服药、严格控制每日进食量是糖尿病控制率的支持因素。
6.成都市社区慢性病管理措施的特色。成都市社区慢性病管理组织机构和职责清晰；注重规划、系统层次地制订政策,确定考核指标和体系；责任医生制的契约式管理结合了多种形式的健康教育；形成了一套包含慢性病医务人员的培训、晋升、考核、激励等完整的、系统的社区人力资源发展机制；慢性病信息网络化并建立了一个类似提供者提醒的预警系统；通过科研推动慢性病管理的发展。
研究结论
社区慢性病管理工作取得了一些成效：1.建立了责任医师制及良好的健康教育大环境；2.随访工作改善了医生与患者的关系；3.以重视预防的意识为先导,各相关政府部门联合行动,慢性病管理工作取得实质性进展；4.分级式管理和契约式管理相结合的模式奠定了注重质量发展的良好基础；5.慢性病管理在社区实现了五位一体的功能。但是存在一些问题,主要是：1.社区卫生服务机构与社会医疗保险机构的结合不太紧密,不能保证足够病源；2.慢性病管理方法和手段上存在不足；3.健康教育不能忽视慢性病防治基础知识；4.全科医生的医疗技术有待提高和出诊服务态度有待改善；5.费用仍然是社区卫生服务机构发展的障碍。
政策建议
促进社区卫生服务机构与社会医疗保险机构的结合,保障慢性病人的健康权益；完善和增加慢性病管理方法和手段,以促进慢性病患者社区卫生服务利用的持续性、控制的有效性；发展自我管理教育,逐步形成病人自我管理；关注成都市慢性病管理薄弱的人群；要加强全科医生的培训,改善全科医生的服务态度,提高全科医生的技术水平；政府待加强对社区卫生服务机构的投入,特别是公共卫生。
研究创新
1.本研究首次在社区慢性病管理条件下,研究糖尿病患者利用社区卫生服务监测治疗疾病的影响因素。
2.本文首次分析了在分级管理和契约式管理相结合的慢性病管理模式形成后的慢性病管理效果。以往的研究局限于小范围的干预。
Objective
The chronic disease have three features of high morbidity rate, high disability rate, high mortality rate. Along with the development of economic and people's living level, chronic patients increased more and more. In 2005 the investigation report of Chinese residents'nourishment and health condition expressed that our country had more than 1.6 hundred million adult hypertension patients. The chronic disease bring heavy disease economy burden to the nation, society, family and the individual, it is urgent to explore cheap and efficient chronic disease management model.
To know health service utilization and managemnet of hypertension patients and diabetes millilus in Community Health Centres (CHCs) in ChengDu, and the control condition of the hypertension and diabetes, this research provided basis for related departments to perfect the model of Chronic Disease Management(CDM) by summarizing the experience and discovering problems.
Methods
By combining quantity with quality analyses, this study evaluated the implementation of the model of Chronic Disease Management (CDM) in CHCs in ChengDu. In this study, document analysis, field observation, depth interview, case example research, and comparison research were performed to investigate and analyze the model of CDM in ChengDu. In details, the model and management measures of hypertension patients and diabetes millilus in CHCs were analyzed by document analysis. The utilization rate of hypertension patients and diabetes millilus in CHCs, the control rate of hypertension and diabetes, the awareness, attitude and behavior change rate were analyzed by the descriptive method. The influencing factors were analyzed by chi-square test or unconditional logistic multiple regression analysis. Factor analysis and hierarchical cluster analysis were adopted to study the satisfaction of hypertension patients and diabetes millilus to CHS.
Results
The results of this study include following:1. The rate of filing health records, standardized-management and the model of CDM in CHCs. In 2006 the rate of filing health records of chronic patients, which include hypertension patients and diabetes millilus, was 28.57%. The rate of standardized-management of high blood pressure, diabetes patients of some area was 55.03% and 54.22%, respectively. In ChengDu the CDM model, which combined management in grades with contractual management, have taken shape.
2. The statue of disease control and utilization of CHCs of the hypertension patients and diabetes millilus.①The demographic and sociology characteristic. There were 2028 patients were investigated. Among them,1716 persons are hypertension patients.590 persons are diabetes millilus.278 persons are the hypertension and diabetes patients.821 persons,40.5% are male.1207 persons,59.5% are female. The oldest was 97 years old and the youngest was 14 years old. Average age was 67.10±10.34 years old.②The utilization statue of CHCs:Most hypertension patients and diabetes millilus monitored and treated the disease in CHCs, The rates were 81.41% and 56.95%, respectively. The utilization frequency include four levels:in a week, more than one week in two weeks, more than two weeks in a month, more than a month. More than two weeks in a month was the tallest frequency for both hypertension patients and diabetes millilus. The rates were 44.8% and 47.5%, respectively. It was necessary to shorten the period of monitoring disease for hypertension patients.③The awareness statue of CHCs:The awareness rate of having to take medicine all life once accept medicine treatment of hypertension patients and diabetes patients were 90.0% and 86.9%, respectively. The awareness rate of normal blood pressure and normal blood sugar were 79.4% and 79.2%, respectively. The rates of knowing the right ones were 48.9% and 35.4%, respectively. The all symptoms of diabetes were known by 299(50.7%). It is necessary to strengthen explaining foundational prevention knowledge to the patients.④The rate of complying with General Practitioner(GP)'s advice to take medicine. The rate of complying with GP's advice to take medicine of hypertension patients and diabetes millilus were high,94.7% and 95.1%, respectively. The ones of regularly complying with GP's were 90.9% and 94.2%, respectively.⑤The statue of behavior changes: after being monitored and treated in CHCs, the rate of getting less angry, doing more exercises and living more regularly were 78.0%,76.7% and 93.0%, respectively. The rate of dieting strictly and doing more exercises were 57.1% and 62.1%, respectively.⑥Filing health records and follow-up:There were 1819 persons,89.7% knew their health records was filed.1829 persons,90.2% were followed up by GP. Follow-up in clinic or through telephone, door-to-door follow-up and follow-up in meeting with all residents were three kinds of methods of follow-up. The proportions were 70.7%, 27.0% and 2.3%, respectively.⑦The control rate:The control rate of hypertension and diabetes were 76.3% and 62.5%, respectively.
3. Health service satisfaction of CDM. Among the factors, the average score of the satisfaction of service attitude was the highest (4.45), and that of the average doctors'technology level was the lowest (4.00). In overall evaluation of the satisfaction to medical organizations,0.1% of the 2006 patients were "very dissatisfied" or "not too satisfied". Main factor analysis indicated that the 7 factors was reduced to 4. Following hierarchical cluster analysis indicated that the total satisfaction of service, expenses, doctors' technology level, service attitude of visiting patients at home were a set. Procedure of Medical treatment, service attitude of interpreting prevention knowlegde of chronic disease were a set. Medical treatment enviornment, service attitude of seeing a doctor were a set. The later tow sets were merged, and then merged the first set to one set.
4. Logistic regression analysis on influencing factors of the CHCs utilization of hypertension patients or diabetes millilus. Age (from 50-year to 69-year), self payment, joining in the Urban Resident. Basic Medical Insurance, awareness of the free charge site of measuring blood pressure, awareness of having to take medicine all life once accept medicine treatment, filing health records and follow-up were protection factors influencing the CHCs utilization of hypertension patients. Not knowing the normal blood pressure was a dangerous factor. Self-payment, joining in the Urban Resident Basic Medical Insurance Scheme, awareness of having to take medicine all life once accept medicine treatment, complying with GP's advice to take medicine, filing health records, follow-up in clinic or through telephone, door-to-door follow-up were protection factors influencing the CHCs utilization of diabetes millilus. Not knowing the normal blood sugar is a dangerous factor.
5. Logistic regression analysis on influencing factors of the control rate of hypertension or diabetes. Awareness of the free charge site of measuring blood pressure, awareness of having to take medicine all life once accept medicine treatment, complying with GP's advice to take medicine regularly, strengthening physical exercises, follow-up in clinic or through telephone, door-to-door follow-up were protection factors influencing the control rate of hypertension. Self-employed, joining in the Urban Employee Basic Medical Insurance Scheme, joining in the Urban Resident Basic Medical Insurance Scheme, joining the New Rural Cooperative Medical Scheme were dangerous factors. The employee/worker/attendant, complying with GP's advice to take medicine, strict control of diet were protection factors influencing the control rate of diabetes.
6. The measure's features of CDM in CHS in ChengdDu city. The organization of CDM had and its clear-cut job responsibility. The government payed attention to the long-term programme, establishing the policy systematic and in gradation and setting up a check-on index system to cadres and others in CHCs. The contractual management model of the duty doctor's system combined with various forms of health education. A complete and systematic development mechanism of community human resources have been posed, including training, rising in rank, check-on, encourages and so on. Chronic disease information was network and established a early-warning system which was similar to provider reminders. The related research pushed the development of CDM.
Conclusions
There are some achievements in CDM in CHCs:The GPs'duty system and good health education environment have been established; Follow-up enhance the relationship between the GPs and the patients; tangible headway was achieved by Consciousness of emphasizing prevention firstly and relevant departments of government cooperating each other; Foundation of laying stress on quality was well established; CDM in community realized five functions of integral wholesed. There are some problems:Relationship between CHCs and social medical insurance institution wasn't closely enough; We still lacked of methods and measures of CDM; Education of prevention and cure knowledge of chronic disease was not deeply and painstakingly; GPs'medical treatment technique and service attitude of visiting a patient at home should be improved; High medical expenses is still a problem to hypertension patients and diabetes patients in CHS.
Policy Suggestions
1. We should combine CHCs with social medical insurance institution closely to safeguard chronic patients'health right; 2. We should increase the methods and measures of CDM to increase the utilization level of CHS continuously and improve the control of chronic disease more effectively; 3. Self-management education should be developed to realize patients self manage their disease; 4. There were some persons who should be paid more attention to; 5. We should enhance training GPs to improve their technique level and their service attitude; 6. Government should invest more to CHCs to develop public hygiene service.
Innovation
1. It is the first time to study the statue of diabetes patients monitoring and treating disease in CHCs and its influencing factors.
2. We firstly evaluated the performance of the CDM management model, which combined management in grades with contractual management.
引文
[1]国家疾病控制中心网站
[2]Centers for Disease Control and Prevention Diabetes Program. National Diabetes Fact Sheet. Centers for Disease Control,2002. Available from ttp://www.cdc.gov/diabetes/pubs/estimates.htm. Accessed 1 September 2005
[3]Vinicor F, Rufo K, Murphy D. Diabetes and public health in the United States. In International Textbook of Diabetes Mellitus.3rd ed. Zimmet P,Ed.,Chichester,WestSusse x,U.K,John Wiley & Sons.2004;p.1785-1792
[4]卫生部统计信息中心.中国卫生服务调查研究：第三次国家卫生服务调查分析报告[R].北京：中国协和医科大学出版社,2004.
[5]WHO. The World Health Report [R].2002.
[6]王立义.社区慢性病管理面临的挑战与对策[J].上海预防医学杂志,2003;15,9：475-476
[7]Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:511-544.
[8]Grumbac K, Bodenheimer T. A primary care home for Americans. Putting the house in order. JAMA 2002;288:889-893.
[9]Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA.2002;288:1775-1779.
[10]Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness.The Chronic Care Model, Part 2. JAMA.2002;288:1909-1914.
[11]Rothman A, Edward H. Chronic illness management. what is the role of primary care. Ann Intern Med 2003;138:256-261.
[12]Julie A.Scbmittdiel, Stepben M. Sbortell, Tbomas G. Rundall, Tbomas Bodendiemer, et al. Effect of primary health care orientation on chronic care management. Ann Fam Med 2006;4:117-123
[13]Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manage Care 1996; 4:12-25
[14]Committee on Quality of Health Care in America, Institute of Medicine:Crossing the Quality Chasm:A New Health System for the 21st Century. Washington DC, National Academy Press 2001
[15]Zgibor JC, Rao H, Wesche-Thobaben J,Gallagher N,McWilliams J,KorytkowskiMT. Improving the quality of diabetes care in primary care practice. J Health care 2004;26:14-21
[16]Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA.2002;288:1775-1779.
[17]国务院：中共中央关于卫生改革与发展的决定.1997
[18]卫生部等十一部门：关于加快发展城市社区卫生服务的意见.2002.
[19]国务院.关于发展城市社区卫生服务的指导意见.2006
[20]卢祖洵.社会医学[M].北京：人民卫生出版社,2003,5
[21]Tollman SM. The Pholela Health Centre-the origins of community oriented primary health care. An appreciation of the work of Sidney and Emily Kark.S Afr Med J 1994;84:653-658
[22]李惠娟,季正明,黄煊,等.社区导向基层医疗模式简介[J].上海预防医学杂志,2002,14(7)：342
[23]陆勇,季正明等.社区卫生定向服务模式在社区慢性病管理中的应用[J].中国慢性病预防与控制,2004,12(2)：73-75
[24]Gretchen A, Trevor J, Sharlene Emerson, David Simmons, Thomas J:Translating the chronic care model into the community, diabetes care 2006;29:811-817
[25]Xilong Pan, Hassan H Dib, Xiaohang Wang and Hong Zhang. Service utilization in community health centers in china:a comparison ananlysis with local hospitals. BMC health services research 2006,6:93-100
[26]1981年成都市年鉴
[27]2004、2005、2006年成都市年鉴
[28]成都市城市社区卫生工作文件汇编
[29]成都市社区卫生服务工作报告
[30]卫生部,科技部,国家统计局.中国居民营养与健康状况调查报告[M].北京：人民卫生出版社,2005：1-25
[31]李静,陈琦,关静,等.全国社区卫生现状调查-东中西部地区社区卫生服务机构三种常见慢性病管理情况分析[J].中国全科医学,2005,8(19)：1565-1567
[32]于志刚,杨杰,刘海波.连续性服务对慢性病管理的作用[J].中国实用乡村医生,2004,11(8)：43-44
[33]陈永,叶选怡,黄玉萍等.社区卫生服务中心慢性病防治模式的探讨[J].丽水学院学 报,2005,27(2)：125-128
[34]王悦宁.我国高血压社区管理模式及效果研究进展[J].预防医学论坛,2009,15(4)：331-333
[35]中国高血压防治指南修订委员会.中国高血压血防治指南(试行2005年修订版全文).北京：人民卫生出版社,2006：2-20
[36]叶任高,陆再英.内科学.5版.北京：人民卫生出版社,2004：843
[37]周春芬.高血压病人系统管理与疗效观察[J].中国慢性病预防与控制,1998,6(3)：181-182
[38]周学富,刘红建,王飞霞.社区高血压系统管理近期效果评估报告[J].实用预防医学,2002,9(1)：10
[39]李华英,胡宝珍.对社区高血压患者进行分级管理的做法和体会[J].中国全科医学,2006,9(2)：227
[40]傅东波,沈贻谔,傅华,等.高血压自我管理方法(高血压俱乐部)初探[J].上海预防医学杂志,2000,12(12)：555-557
[41]叶文,于普林,刘雪荣,等.社区高血压患者自我管理项目定性评价[J].中华全科医师杂志,2004,3(3)：178-179
[42]赵芳,郑建中,陈博文,等.成都市玉林社区高血压患者契约式管理效果分析[J].中华流行病学杂志,2003,24(10)：897
[43]童思未.社区契约式管理对高血压患者控制血压的效果[J].中国慢性病预防与控制,2006,15(6)：269
[44]2005年成都市社区卫生服务工作统计报表
[45]2006年成都市社区卫生服务工作统计报表
[46]2007年成都市社区卫生服务工作统计报表
[47]吴阳丰.肥胖：必须引起国人重视的流行病[J].中华流行病学杂志,2002,23(1)：3-4
[48]吕岩鱼,李子贵,王红利.北京市中关村高血压病例管理效果评价[J].中华流行病学杂志,2005,26(6)：400-403
[49]刘继红,田秀珍,孙力光,等.北京市石景山八角社区高血压综合干预效果分析[J].中国全科医学,2006,9(15)：1267-1269
[50]Haskett t.Chronic illness management:Changing the system. Home health care management and practice.2006; 18(6):492-494
[51]Anderson RM, Funnell MM, Arnold MS. Using the empowerment approach to help patients change behavior. In Rubin B,Anderson B,eds. Practical Psychology for Diabetes Clinicians. Alexandria,Va:American Diabetes Association; 1996.
[52]Arnold MS, Butler RM, Anderson RM. et al.guidelines for facilication a patient empowerment program.Diabetes Educ.1995;21:308-312.
[53]Anderson RM, Funnell MM.Compliance and adherence are dysfunctional concept in diabetes care. Diabetes Educ.2000;26:597-604.
[54]柴秀琴,刘建平.社区健康教育对提高糖尿病患者遵医行为效果观察[J].社区医学杂志,2007,5(11)：54-55
[55]杨惠勤,毛建国,傅东波,等.某社区慢性病自我管理健康教育对自我效能的影响[J].上海预防医学杂志,2003,15(7)：313-323
[56]Fu dongbo, Fuhua, Patrick MG, et al.Implementation and quantitative evaluation of chronic disease self management programme in Shanghai, China:randomized controlled trail[J]. Bulletin of the World Health Organization.2003;81(3):174-182
[57]傅东波,傅华,Patrick Mc Cowan等.上海慢性病自我管理项目实施效果的评价[J].中国公共卫生,2003,18(2)：223-225
[58]Asra Warsi, Philip S.Wang, Michael P.Lavalley, et al. Self-management education programs in chronic disease. Arch Intern Med,2004,164:1641-1649
[59]ASCC高血压协作组.我国部分地区高血压登记调查及治疗达标研究[N].中国医学论坛报告,2007-05-10
[60]范建洪.某社区糖尿病健康教育实践[J].上海预防医学杂志,2009,21(10)：515,517
[61]李芳健,周红伟,黄青林,等.广州市某区12家社区卫生服务机构满意度调查分析[J].中华全科医学,2008,6(9)：955-956
[62]刘伟,陆晓浓,王秀瑛,等.医疗保险经费用于慢性病管理的可行性探讨中国卫生经济[J],2007：26(2)：33-35
[63]Scott R, James M, Enkhe B, et al. Interventions used in disease management programmes for patients with chronic illness-which one work?Meta-analysis of published reports. BMJ 2002;325:925-932
[64]Vinicor F, Cohen SJ, Mazzuca SA, Moorman N, Wheeler M, Kuebler T, et al.DIABEDS:a randomized trial of the effects of physician and/or patient education on diabetes patient outcomes. J Chronic Dis 1987;40:345-56.
[65]Bogden PE, Koontz LM, Williamson P, Abbott RD. The physician and pharmacist team. An effective approach to cholesterol reduction. J GenIntern Med 1997; 12:158-64.
[66]De Sonnaville J, Bouma M, Colly LP, Deville W, Wijkel D, Heine RJ. Sustained good glycaemic control in NIDDM patients by implementation of structured care in general practice: 2-year follow-up study. Diabetologia 1997;40:1334-40.
[67]Kinmonth AL, Woodcock A, Griffin S, Spiegal N, Campbell MJ. Randomised controlled trial of patient centred care of diabetes in general practice:impact on current wellbeing and future disease risk. The Diabetes Care From Diagnosis Research Team. BMJ 1998;317:1202-8.
[68]Ridgeway NA, Harvill DR, Harvill LM, Falin TM, Forester GM, Gose OD.Improved control of type 2 diabetes mellitus:a practical education/behavior modification program in a primary care clinic. South Med J1999;92:667-72.
[69]Weinberger M, Kirkman MS, Samsa GP, Shortliffe EA, Landsman PB,Cowper PA, et al. A nurse-coordinated intervention for primary carepatients with non-insulin-dependent diabetes mellitus:impact onglycemic control and health-related quality of life. J Gen Intern Med1995;10:59-66.
[70]Fielding JE, Knight K, Mason T, Klesges RC, Pelletier KR. Evaluation of the IMPACT blood pressure program. J Occup Med 1994;36:743-6.
[71]Hypertension Detection and Follow-up Program Cooperative Group.Five-year findings of the hypertension detection and follow-up program.II. Mortality by race-sex and age. JAMA 1979;242:2572-7.
[72]Chodosh J, Morton SC, Mojica W, Maglione M, et al. Meta-Analysis:Chronic disease self-management programs for older adults. An Inter Med 2005; 143:427-438
[73]韩秀芩,蔡常云,雍爱玲,等.10年社区健康教育对高血压合并症的影响[J].中国全科医学,2006,12：1454-1455
[74]陈光.高血压患者健康教育近况[J].中国全科医学,2005,8：1020
[75]李建陶.高血.压的健康教育与疗效观察[J].中国误诊学杂志,2003.3：463
[76]蚁丽农,郭玉碧,赖胜芳.护理健康教育在高血压患者和脑卒中的预防效果评价[J].河北医药,2004,26：519
[77]姬克,李颢,蒙艳丽.医患互动式健康教育对高血压效果评价[J].中国全科医 学,2004,7：1410
[78]郭淑霞,孙凤,徐上知,等.社区居民高血压患病率、知晓率、治疗和控制状况[J].现代预防医学,2006,33(11)：2076-2078
[79]徐恒酱戈,张凤梅,xu heng-jian,等.高校教职工高血压患病率、知晓率、治疗率和停药后血压变化情况[J].现代预防医学,2006,33(12)：2269-2271
[80]黄锦荣,何茶叶,边长艳.某高校高血压社区防治研究[J].现代预防医学,2007,34(16)：3134-3135
[81]陆云霞,施侣元.居民糖尿病防治知识认知程度及影响因素分析[J].中国公共卫生,2004,20(5)：628-629
[82]李彗,孟庆跃,涂诗意,等.山东农村居民高血压患者服药依从性及其影响因素分析[J].中国卫生事业管理,2008,(7)：478-480
[83]李琦.健康教育对社区高血压患者相关知识知晓情况及遵医行为的影响[J].中国慢性病预防与控制,2009,17(1)：78-79
[84]周根洪,许艳明,王俊,等.姜堰市社区高血压患者药物治疗依从性分析[J].中国慢性病预防与控制,2009,17(5)：542-543
[85]顾东风,Jiang He,吴锡桂.中国成年人高血压患病率、知晓率、治疗和控制状况[J].中华预防医学杂志,2003,37(2)：84-89.
[86]李存艳,张开金,胡大洋,等.居民社区卫生服务知晓与利用的关系及其影响因素分析[J].现代预防医学,2007,34(7)：1242-1245
[87]Loring KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self-management in patient with chronic arthritis has sustained health benefits which reducing health care costs [J]. Arthritis and Rheumatism.1993;36:439-446
[88]周淑新编译.对慢性病自我表现管理的支持[J].中国全科医学,2005,8(24)：2033-2035
[89]赵艳青,吕军.慢性病管理的新理念-内行患者计划[J].解放军健康.2006,1：11
[90]J.H Barlow, J.Sturt, H.Hearnshaw. Self-management intervention for people with chronic condition in primary care:Examples from arthritis, asthma and diabete. Chronic respiratory disease 2004; 1(4):213-220
[91]Von Korff M, Gruman J, Schaefer J, et al.Collaborative management of chronic illness. Ann Intern Med.1997;127:1097-1102
[92]Funnell MM, Anderson RM, Arnold MS, et al. Empowerment:an idea whose time has come in diabetes education. Diabetes Educ 1991;17:37-41
[93]D'Zurilla T. Problem solving therapy. New York, NY. Springer Publishing Co;1986.
[94]Lorig K, Holman H, Sobel D, et al. Living a healthy life with chronic condition. Palo Alto, Claif:Bull Publishing Co; 1994
[95]Holman H, Lorig K. Patients as partners in managing chronic disease. BMJ 2000;320:526-527
[96]Funnell MM, Anderson RM.The problem with compliance in diabetes.JAMA.2000;284:1709
[97]Chronic Disease Self-Management Leader's Manual (revised). Palo Alto, Claif:Stanford Patient Education Research Center; 1997
[98]Aubert RE, Herman WH, Waters J, MooreW, Sutton D, Peterson BL, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial. Ann Intern Med 1998;129:605-12.
[99]Benjamin EM, Schneider MS, Hinchey KT. Implementing practice guidelines for diabetes care using problem-based learning. A prospective controlled trial using firm systems. Diabetes Care 1999;22:1672-8.
[100]王源江,程春华,刘群时,等.吉林地区糖尿病流行病学调查[J].中华预防医学杂,2000,34：164
[101]杨泽,于普林,范钦颖,等.北京市中老年人Ⅱ型糖尿病流行病学调查[J].老年医学保健,2001,7：142-144
[102]周小军,袁兆康,万红,等.赣州市社区居民对社区卫生服务的认知及利用[J].中华全科医师杂志,2006,5(9)：559-561
[103]张本,张媛,刘衡川,等.成都市社区慢性阻塞性肺疾病患者卫生服务利用及其影响因素分析[J].四川大学学报(医学版),2007,38(2)：316-320
[104]刘军安,卢祖洵,黄忠科,等.深圳市门诊和住院服务满意度评估及比较分析[J].中国卫生事业管理,2006,9：552-554
[105]汪胜,姜润生,郭清.社区卫生服务患者满意度影响因素分析[J].中国农村卫生事业管理,2006,26(11)：9-1
[106]宋桂荣,刘红波,程然,等.门诊患者的满意度调查与分析评价[J].中国卫生统计,2006,23(1)：53-54
[107]唐智柳,董恒进,陈英耀,等.住院患者的满意度调查分析[J].中华医院管理杂 志,2000,16(4)：252-254
[108]郭清,李晓惠,王小合,等.下岗职工家庭利用社区卫生服务的影响因素分析[J].中国全科医学,2006,9(15)：1298-1300
[109]杜娟,赵艳萍,郭爱民,等.大兴区黄村镇农村居民社区卫生服务的需求、利用及满意度调查[J].首都医科大学学报,2005,26(6)：691-694
[110]高俊岭,张波.银川市社区卫生服务知晓率和利用率调查分析[J].社区医学杂志,2006,4(5):1-3
[111]Kenneth AH, Thomas LC. Self-Management of Chronic Disease Handbook of Clinical Interventions and Research [M]. Orlando:Academic Press,1986
[112]傅弦琴,庄康路,张芳,等.2005年潍坊社区居民慢性病现状调查[J].实用全科医学,2007,5(3)：256-257
[113]Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA 2002;288:2469-2475
[114]Lorig K. Self-management of chronic illness:a model for the future. Generations 1993;17:11-14
[115]翟萍.高血压患者自我管理失败的原因分析[J].实用全科医学,2008,5(8)：713-714
[1]Centers for Disease Control and Prevention Diabetes Program. National Diabetes Fact Sheet. Centers for Disease Control,2002. Available from http://www.cdc.gov/diabetes/pubs/estimates.htm. Accessed 1 September 2005
[2]Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Millbank,1996;4:511-544
[3]Committee on Quality of Health Care in America,Institute of Medicine:Crossing the Quality Chasm. A New Health System for the 21st Century. Washington.DC, National Academy Press 2001
[4]Zgibor JC, Rao H, Wesche-Thobaben J, Gallagher N, McWilliams J, Korytkowski MT. Improving the quality of diabetes care in primary care practice. J Health care 2004;26:14-21
[5]Vinicor F, Rufo K, Murphy D. Diabetes and public health in the United States. In International Textbook of Diabetes Mellitus.3rd ed. Zimmet P, Ed., Chichester,West Sussex, U.K., John Wiley & Sons 2004; 1785-1792
[6]Grumbach K, Bodenheimer T. A primary care home for Americans. Putting the house in order. JAMA 2002;288:889-893.
[7]Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775-1779.
[8]Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness.The Chronic Care Model, Part 2.JAMA 2002;288:1909-1914.
[9]Rothman A, Edward H. Chronic illness management. what is the role of primary care. Ann Intern Med 2003;138:256-261.
[10]Julie A.Scbmittdiel, Stephen M.Sbortell, Tbomas G.Rundall, Tbomas Bodendiemer, et al. Effect of primary health care orientation on chronic care management.Ann Fam Med 2006;4:117-123
[11]Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Manage Care 1996; 4:12-25
[12]Bodenheimer T, Lorig K, Holman H, Grumbach K. Patient self-management of chronic disease in primary care. JAMA 2002;288:2469-2475
[13]Gretchen A, Trevor J, Sharlene Emerson, David Simmons, Thomas J. Translating the chronic care model into the community. Diabetes care 2006;29:811-817
[14]Tollman SM. The Pholela Health Centre-the origins of community oriented primary health care. An appreciation of the work of Sidney and Emily Kark.S Afr Med J 1994;84:653-658
[15]李惠娟,季正明,黄煊,等.社区导向基层医疗模式简介[J].上海预防医学杂志,2002,14(7)：342
[16]陆勇,季正明.社区卫生定向服务模式在社区慢性病管理中的应用[J].中国慢性病预防与控制,2004,12(2)：73-75
[17]李静,陈琦,关静,等.全国社区卫生现状调查-东中西部地区社区卫生服务机构三种常见慢性病管理情况分析[J].中国全科医学,2005,8(19)：1565-1567
[18]Baker D, Middleton E, Campbell S. The impact of chronic disease management in primary care on inequality in asthma severity. Journal of public health medicine 2003;25(3):258-260
[19]Scott R, James M, Enkhe B, et al. Interventions used in disease management programmes for patients with chronic illness-which one work?Meta-analysis of published reports. BMJ 2002;325:925-932
[20]Anderson RM, Funnell MM, Butler PM, Arnold MS, Fitzgerald JT. feste CC. Patient empowerment:results of a randomized controlled trail:Diabetes care 1995; 18:943-949.
[21]Toward a research agenda for the American Association of Diabetes Educators. Diabetes Educ 2001;27:899-907
[22]Anderson RM, Funnell MM, Arnold MS. Using the empowerment approach to help patients change behavior. In Rubin B, Anderson B, eds. Practical Psychology for Diabetes Clinicians. Alexandria, Va:American Diabetes Association; 1996.
[23]Anderson RM, Funnell MM.Compliance and adherence are dysfunctional concept in diabetes care. Diabetes Educ 2000;26:597-604.
[24]Loring KR, Mazonson PD, Holman HR. Evidence suggesting that health education for self-management in patient with chronic arthritis has sustained health benefits which reducing health care costs. Arthritis and Rheumatism 1993;36:439-446
[25]杨惠勤,毛建国,傅东波等.某社区慢性病自我管理健康教育对自我效能的影响[J].上海预防医学杂志,2003,15(7)：313-323
[26]Fu dongbo, Fuhua, Patrick MG, et al.Implementation and quantitative evaluation of chronic disease self management programme in Shanghai, China:randomized controlled trail. Bulletin of the World Health Organization 2003;81(3):174-182
[27]傅东波,傅华,Patrick Mc Cowan,等.上海慢性病自我管理项目实施效果的评价[J].中国公共卫生,2003,18(2)：223-225
[28]于志刚,杨杰.连续性服务对慢性病管理的作用[J].全科医学知识窗,2004,11(8)：43-44
[29]陈永,叶选怡,黄玉萍,等.社区卫生服务中心慢性病防治模式的探讨[J].丽水学院学报,2005,27(2)：125-128
[30]周淑新编译.对慢性病自我表现管理的支持[J].中国全科医学,2005,8(24)：2033-2035
[31]赵艳青,吕军.慢性病管理的新理念-内行患者计划[J].解放军健康.2006,1：11
[32]J.H.Barlow, J.Sturt, H.Hearnshaw. Self-management intervention for people with chronic condition in primary care:Examples from arthritis, asthma and diabete. Chronic respiratory disease 2004; 1(4):213-220
[33]Holman H, Lorig K. Patients as partners in managing chronic disease. BMJ 2000;320:526-527
[34]Funnell MM, Anderson RM. The problem with compliance in diabetes. JAMA 2000;284:1709
[35]Arnold MS, Butler RM, Anderson RM. et al. Guidelines for facilication a patient empowerment program.Diabetes Educ 1995;21:308-312.
[36]Francis j.crosson and Philip madvig. Does population management of chronic disease lead to lower costs of care. Health affairs 2004,23(6):76-78
[37]Von Korff M, Gruman J, Schaefer J, et al. Collaborative management of chronic illness. Ann Intern Med 1997;127:1097-1102
[38]Funnell MM, Anderson RM, Arnold MS, et al. Empowerment:an idea whose time has come in diabetes education. Diabetes Educ 1991;17:37-41
[39]D'Zurilla T. Problem solving therapy. New York, NY. Springer Publishing Co;1986.
[40]Lorig K, Holman H, Sobel D, et al. Living a healthy life with chronic condition. Palo Alto, Claif:Bull Publishing Co; 1994
[41]Corbin J, S trauss A. Unending Work and care managing chronic illness at home. San Francisco,calif:Jossey-Bass Publishers; 1998.
[42]Chronic Disease Self-Management Leader's Manual (revised). Palo Alto, Claif:Stanford Patient Education Research Center; 1997
[43]Gibson PG, Coughlan J, Wilson AJ, et al. Self-management education and regular Practitioner review with asthma. Oxford, England:Cochrane library, update software;2001:issue 4.
[44]Chodosh J, Morton SC, Mojica W, Maglione M, et al. Meta-Analysis:Chronic disease self-management programs for older adults. Annals of Internal medicine 2005,143:427-438.
[45]Loring K, Sobel D, Stewart A, et al. Evidence suggesting that a chronic disease self-management programme can improve health status while reducing hospitalization:a randomized trail. Medical Care 1999,37(1):5-14
[46]Waholtson PB, Town GI, Holbrook N, et al. Evaluation of a self-management plan for chronic obstructive pulmonary disease. European Respiratory Journal 1997,10(6):1267-1271
[47]Asra Warsi, Philip S.Wang, M ichael P.Lavalley, et al. Self-management education programs in chronic disease.. Arch Intern Med 2004,164:1641-1649
[48]Glasgow RE, LaChance PA, toober DJ, brown J, Hampson SE, Riddle MC. Long-term effects and costs of brief behavioral dietary intervention for patients with diabetes delivered from the medical office. Patients Edu Count 1997;32:175-184
[49]Aubert RE, Herman WH, Waters J, Moore W, Sutton D, Peterson BL, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization. A randomized, controlled trial. Ann Intern Med 1998; 129:605-12.
[50]Benjamin EM, Schneider MS, Hinchey KT. Implementing practice guidelines for diabetes care using problem-based learning. A prospective controlled trial using firm systems. Diabetes Care 1999;22:1672-8.
[5l]Vinicor F, Cohen SJ, Mazzuca SA, Moorman N, Wheeler M, Kuebler T, et al. Diabetes:a randomized trial of the effects of physician and/or patient education on diabetes patient outcomes. J Chronic Dis 1987;40:345-56.
[52]Bogden PE, Koontz LM, Williamson P, Abbott RD. The physician and pharmacist team. An effective approach to cholesterol reduction. J GenIntern Med 1997; 12:158-64.
[53]De Sonnaville J, Bouma M, Colly LP, Deville W, Wijkel D, Heine RJ. Sustained good glycaemic control in NIDDM patients by implementation of structured care in general practice: 2-year follow-up study. Diabetologia 1997;40:1334-40.
[54]Kinmonth AL, Woodcock A, Griffin S, Spiegal N, Campbell MJ. Randomised controlled trial of patient centred care of diabetes in general practice:impact on current wellbeing and future disease risk. The Diabetes Care From Diagnosis Research Team. BMJ 1998;317:1202-8.
[55]Ridgeway NA, Harvill DR, Harvill LM, Falin TM, Forester GM, Gose OD.Improved control of type 2 diabetes mellitus:a practical education/behavior modification program in a primary care clinic. South Med J 1999;92:667-72.
[56]Weinberger M, Kirkman MS, Samsa GP, Shortliffe EA, Landsman PB,Cowper PA, et al. A nurse-coordinated intervention for primary carepatients with non-insulin-dependent diabetes mellitus:impact onglycemic control and health-related quality of life. J Gen Intern Med 1995; 10:59-66.
[57]Fielding JE, Knight K, Mason T, Klesges RC, Pelletier KR. Evaluation of the IMPACT blood pressure program. J Occup Med 1994;36:743-6.
[58]Hypertension Detection and Follow-up Program Cooperative Group.Five-year findings of the hypertension detection and follow-up program.Ⅱ. Mortality by race-sex and age. JAMA 1979;242:2572-7.
[59]韩秀芩,蔡常云,雍爱琳,等.10年社区健康教育对高血压合并症的影响[J].中国全科医学,2006,12：1454-1455
[60]陈光.高血压患者健康教育近况[J].中国全科医学,2005,8：1020
[61]李建陶.高血压的健康教育与疗效观察[J].中国误诊学杂志,2003.3：463
[62]蚁丽农,郭玉碧,赖胜芳.护理健康教育在高血压患者和脑卒中的预防效果评价[J].河北医药,2004,26：519
[63]Lorig KR, Ritter P, Stewart AL, et al. Chronic disease self-management program:2-year health status and health care utilization outcomes. Med Care 2001;39:1217-1223.
[64]Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization. Med Care. 1999;37:5-14
[65]Leveille SG, Wagner EH, Davis C, et al. Preventing disability and managing chronia illness in frail older adults:a randomized trail of acommunity-based partnership with primary care. J Am Geriatr Soc 1998;46:1191-1198.
[66]Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion intervention:RE-AIM framework.. Am J Public Health 1999;89:1323-1327.
[67]Glasgow RE, Eakin EG, Toobert DJ. How generalizable are the results of diabetes self-management results:the impact of participation and attrition.Diabetes Educ 1996;22:573-585.
[68]B. Fireman, J. Bartlett, J. Selby. Can Disease Management Reduce Health Care Costs by Improving Quality. Health Affairs 2004; 23 (6):63-75.
[69]V.G. Villagra and T. Ahmed. Effectiveness of a Disease Management Program for Patients with Diabetes.Health Affairs 2004;23 (4):255-266.
[70]Mary P. The influence of social support an chronic illness self-management:a review and directions for research, health education and behavior 2003,30 (2):170-195
[71]Kim R, Langer B. Policy approaches to chronic disease management. Home Health Care Management and Practice 2006;18(6):452-462
[72]Haskett T. Chronic illness management:Changing the system. Home Health Care Management and Practice 2006;18(6):492-494
