中国全科医学 ›› 2024, Vol. 27 ›› Issue (05): 563-569.DOI: 10.12114/j.issn.1007-9572.2023.0513

• 论著·专病管理·糖尿病 • 上一篇    

价值共创视角下糖尿病社区管理模式实践与思考

牛路瑶1, 营心语1, 张树琴2, 安志新2, 季婧雅1, 刘跃华3,*(), 高月霞1,*()   

  1. 1.226019 江苏省南通市,南通大学公共卫生学院
    2.226300 江苏省南通市通州区平潮中心卫生院
    3.100084 北京市,清华大学健康中国研究院
  • 收稿日期:2023-05-22 修回日期:2023-09-26 出版日期:2024-02-15 发布日期:2023-11-21
  • 通讯作者: 刘跃华, 高月霞

  • 作者贡献:牛路瑶、营心语、张树琴负责文章的构思与设计、国内外文献的收集整理与归纳、论文撰写;安志新、季婧雅负责国内外文献的收集整理与补充、表格绘制与整理;刘跃华、高月霞负责文章的构思与设计、文章修订、质量控制及审校。
  • 基金资助:
    国家社会科学基金资助项目(22ZDA030); 南通市科技计划资助项目(MS12021062)

Practice and Reflection on Diabetes Community Management Model from the Perspective of Value Co-creation

NIU Luyao1, YING Xinyu1, ZHANG Shuqin2, AN Zhixin2, JI Jingya1, LIU Yuehua3,*(), GAO Yuexia1,*()   

  1. 1. School of Public Health, Nantong University, Nantong 226019, China
    2. Pingchao Central Health Service Center, Tongzhou District, Nantong 226300, China
    3. Institute for Healthy China, Tsinghua University, Beijing 100084, China
  • Received:2023-05-22 Revised:2023-09-26 Published:2024-02-15 Online:2023-11-21
  • Contact: LIU Yuehua, GAO Yuexia

摘要: 中国是全球糖尿病患病率增长较快的国家之一,也是糖尿病患者最多的国家。《"健康中国2030"规划纲要》明确提出,要进一步防控重大疾病,实施糖尿病防治行动,指导糖尿病患者加强健康管理,延迟或预防糖尿病发生、发展。近20年来,价值共创理论在健康服务领域应用发展较好,不同国家(地区)探索低成本、高效果的方案以预防和控制糖尿病发生,但目前在国内慢性病管理领域较为缺乏。本文基于价值共创视角,以基层社区为研究分析点,进一步总结国内外慢性病管理经验,从主动健康、组织引导、数字技术、激励考核4个方面提出展望,为优化完善基层糖尿病管理的服务体系,建立基于价值共创的多元主体协同参与社区慢性病管理模式,实现慢性病管理的共创、共治、共享提供参考。

关键词: 糖尿病, 慢性病管理, 价值共创, 社区卫生服务, 综述

Abstract:

China is one of the countries with the fastest growing prevalence of diabetes in the world, and also has the largest number of people with diabetes. The "Health China 2030" plan clearly proposes to further prevent and control major diseases, implement diabetes prevention and control, and guide patients with diabetes to strengthen health management and delay or prevent the development of diabetes. In the past 20 years, value co-creation theory has been well developed in the field of health services, and different countries (regions) have explored programs to prevent and control diabetes at low cost and high effectiveness, but it is currently lacking in the field of chronic disease management in China. Based on the perspective of value co-creation, this paper further summarizes the domestic and international experience of chronic disease management taking community as the research and analysis point, proposes the prospect from four aspects of active health, organizational guidance, digital technology, and incentive assessment, which provides references for optimizing and improving the service system of diabetes management at primary health care, establishing a model of collaborative participation of multiple subjects in community chronic disease management based on value co-creation, and realizing co-creation, co-management and sharing of chronic disease management.

Key words: Diabetes mellitus, Chronic disease management, Value-co-creation, Community health services, Review