关键词: 家庭医生, 健康管理, 德尔菲法, 质量监测指标, 糖尿病, 高血压

Abstract: Background　Evidence-based，high-quality and clinically applicable high-level health service is one of the important promoters to achieve the reform goals of improving people's health and patients' medical experience，as well as the efficiency of health services. With the promotion of contracted family doctor services，it is very important to assess the quality of such services for patients with chronic diseases. However，there is a lack of relevant criteria and assessment indices in China although there are various foreign criteria and systems for chronic disease management. Objective　To develop hypertension and diabetes health management quality indicators in China's primary care based on the experience of the US and the UK，and assess their applicability in Chengdu's Wuhou District. Methods　Based on the relevant contents of NHS-QOF，NCQA-PCMH and China basic public service specification，the first draft of "two diseases" health management quality index system is constructed. From December 2018 to June 2019，26 experts were invited to conduct two rounds of correspondence by Delphi method to form the final draft of the index system. The consensus index system is applied to the residents' health archives center of Wuhou District，the relevant population data are extracted according to the index definition，and the problems or barriers directly identified in the test process were analyzed，as well as the impact of the index system on the service quality of the contracted service team of family doctors. Results　The response rate，authority coefficients and Kendall's W were 100.0%（14/14），0.772，0.609（χ2=87.039，P<0.001），respectively，for the first round of expert consultation regarding hypertension management quality indicators in primary care，and were 87.5%（7/8），0.838，0.298（χ2=37.522，P<0.001），respectively，for the second round. The response rate，authority coefficients and Kendall's W were 100.0%（16/16），0.781，0.513（χ2=69.312，P<0.001），respectively，for the first round of expert consultation regarding diabetes management quality indicators in primary care，and were 87.5%（7/8），0.848，and 0.688（χ2=48.181，P<0.001）respectively，for the second round. Finally，a hypertension management quality system with three domains and 14 indicators，and a diabetes management quality system with three domains and 11 indicators，used for assessing family doctor services for hypertension and diabetes in primary care were developed. In terms of extracting data，we can directly extract the information used for 13 indicators. As the reading values of blood pressure are obtained by the monitoring of equipment，the accuracy of blood pressure needs to be further verified. For 12 indicators can not be extracted directly，we obtain five of them through improving the information system，and obtain other seven through other means of investigation. At the same time，the verification and application of monitoring indicators in Wuhou District has improved the family doctor's chronic disease management ability，and the chronic disease management has changed from process management to result management. Conclusion　There is no obvious cognitive difference between domestic experts on hypertension and diabetes management quality indicators in primary care. The information for most of indicators can be directly fetched and used for monitoring，feedback and assessment in the areas with residents' health records center. The application effect of the monitoring indicators is obvious.

Key words: Family doctor, Health management, Delphi method, Quality monitoring, Diabetes, Hypertension