In 2019, the National Health Commission launched the construction of compact county medical alliance to strengthen chronic diseases management in primary care, and the construction of chronic disease management models varies among county medical alliance sites. Xindu District, as one of the first national compact county medical alliance sites in Sichuan Province, has explored both dimensions of theoretical and practical innovation in the construction of the innovative model of chronic disease management in compact county medical alliance with treatment-prevention integration, providing a new approach for the innovative development of primary compact county medical alliance in China.

To analyze the innovation model and its effectiveness of chronic disease management in compact county medical alliance with treatment-prevention integration of Xindu District with the experience of international integrated medical models.

The chronic disease management in compact county medical alliance with treatment-prevention integration of Xindu District was constructed with "one center, two integration, three reforms and four safeguard mechanisms" under the leadership of Xindu District Health Bureau, to strengthen the management of chronic diseases mainly including hypertension and diabetes.

As of June 2022, the number of hypertension or diabetes patients under standardized management in the district increased by 50.87% compared with the initial stage of construction, the number of hypertension or diabetes patients increased by 55.28% and 49.04%, respectively; while the proportion of patients with HbA_1c<7% or BP<140/90 mmHg (1 mmHg=0.133 kPa) increased by 70.69% and 115.28% in the past year among them, respectively. The outpatient visits of primary care increased by 14.30% in one year, among which the outpatient visits for hypertension or diabetes increased by 36.01%; while downward referrals within medical communities increased by 14.55%, creating a number of demonstration units for the transformation of treatment-prevention integration in primary care.

The innovative model of chronic disease management in compact county medical alliance with treatment-prevention integration of Xindu District has a significant effect on improving the quality and efficiency of chronic disease management in primary care.

2019年国家卫生健康委启动了紧密型县域医共体的建设工作，以强化基层慢性病管理，各县域医共体试点慢性病管理模式构建情况不尽相同。新都区作为四川省首批国家紧密型县域医共体建设试点县之一，在医防融合慢性病管理创新模式的构建过程中进行了理论创新和实践创新两个维度的探索，为我国基层紧密型医共体的创新发展提供了一种思路。

结合国际整合型医疗模式的经验，分析新都区紧密型县域医共体医防融合慢性病管理创新模式及其成效。

2019年6月至2022年6月，新都区在区卫生健康局牵头下，构建了"1个中心，2个整合，3个变革，4个保障"的医防融合慢性病管理模式，强化以高血压、糖尿病为主的慢性病管理工作。

截至2022年6月，全区高血压、糖尿病规范化管理人数较建设初期增长50.87%；其中糖尿病、高血压管理人数分别增长55.28%、49.04%；糖尿病患者中糖化血红蛋<7%的人群比例、高血压患者中血压<140/90 mmHg（1 mmHg=0.133 kPa）的人群比例也在近1年内分别增长了70.69%、115.28%；全区基层门诊量在一年内增长了14.30%，其中高血压、糖尿病的门诊量增长达36.01%；1年内医共体内下转患者增长了14.55%；并打造了一批基层医防融合转型示范单位。

新都区紧密型县域医共体医防融合的创新型慢性病管理模式，对基层慢性病管理提质增效有明显效果。