Abstract: Background Surgery is one of the main means of treating colorectal cancer. However，patients with colorectal cancer need to face many physical and psychological problems after surgery，which seriously affects patients' treatment outcomes and quality of life，so how to carry out effective postoperative management is extremely important. Objective To investigate the effectiveness of an integrated hospital-community-patient chronic disease management pathway intervention for postoperative colorectal cancer patients. Methods Based on different postoperative interventions，colorectal cancer patients were divided into a control group （n=40） and a co-management group （n=36），with the control group implementing conventional postoperative interventions and the co-management group following a constructed integrated chronic disease pathway for co-management. Changes in laboratory indices，recurrent metastasis，death，postoperative complications，quality of life，and anxiety were compared between the two groups before and after surgery. Results At 3 and 6 months postoperatively，patients in the co-management group had lower carcinoembryonic antigen levels than patients in the control group （1.4 ng/mL vs.3.2 ng/mL，χ2 =-4.653，P<0.001；2.6 ng/mL vs. 3.8 ng/mL，χ2 =-3.634，P<0.001）. The incidence of recurrent metastases was not significantly different from that of the control group at 3 months postoperatively （P>0.05），while at 6 months postoperatively，the incidence of recurrent metastases was lower in the co-management group than in the control group （5.6% vs. 22.5%，χ2 =4.395，P=0.036）；in addition，the incidence of complications was lower in the co-management group than in the control group at both 3 and 6 months postoperatively（0 vs. 16.2%，χ2 =3.981，P=0.046；5.6% vs. 25.0%，χ2 =5.388，P=0.020）. However，the difference in mortality at 6 months postoperatively between the two groups was not significant （2.8% vs. 7.5%，χ2 =0.165，P=0.685）. In quality of life scores at 6 months and 1 year postoperatively，the co-management group was higher than control patients ［（48.74±2.16）points vs. （44.73±3.41）points，t=-5.922，P<0.001；（42.03±1.94）points vs.（36.98±4.65）points，t=-5.952，P<0.001］，and the anxiety scores were lower in the co-management group than in the control patients ［（60.12±6.23）points vs.（63.56±4.72）points，t=2.650，P=0.010；（66.49±5.67）points vs.（72.41±5.25）points，t=4.600，P<0.001］. Conclusion The integrated hospital-community-patient chronic disease management pathway can reduce postoperative complications，decrease recurrence and metastasis of colorectal cancer，improve quality of life，and improve anxiety symptoms，and is of great value to the prognosis of postoperative colorectal cancer patients.

Key words: Colorectal cancer, Postoperative management, Chronic disease management, Integrated pathway, Retrospective cohort study

摘要： 背景 手术是治疗结直肠癌的主要手段之一。然而，手术后肠癌患者需要面对许多身体和心理方面的问题，这严重影响到患者的治疗效果和生活质量，因此如何进行有效的术后管理极为重要。目的 本研究主要探讨了医院-社区-患者慢病管理一体化路径干预对结直肠癌术后患者的有效性。方法 根据不同的术后干预方式，将结直肠癌患者分为对照组（n=40）和联合管理组（n=36），对照组实施常规的术后干预，联合管理组遵循构建的慢病一体化路径进行联合管理。比较两组患者术前和术后的实验室指标、复发转移、死亡、术后并发症、生活质量以及焦虑情况的变化。结果 术后3个月和6个月，联合管理组患者的癌胚抗原水平均低于对照组患者（1.4 ng/mL vs.3.2 ng/mL，χ2 =-4.653，P<0.001；2.6 ng/mL vs. 3.8 ng/mL，χ2 =-3.634，P<0.001）；术后3个月联合管理组患者的复发转移发生率与对照组差异无显著性（P>0.05），而在术后6个月，联合管理组患者的复发转移发生率低于对照组患者（5.6% vs. 22.5%，χ2 =4.395，P=0.036）；此外，在术后3个月和6个月，联合管理组患者的并发症发生率均低于对照组患者（0 vs. 16.2%，χ2 =3.981，P=0.046；5.6% vs. 25.0%，χ2 =5.388，P=0.020）。但两组患者在术后6个月的死亡率方面差异不具有显著性（2.8% vs. 7.5%，χ2 =0.165，P=0.685）。在患者术后6个月和1年的生命质量评分中，联合管理组均高于对照组患者［（48.74±2.16）分vs.（44.73±3.41）分，t=-5.922，P<0.001；（42.03±1.94）分vs.（36.98±4.65）分，t=-5.952，P<0.001］，在焦虑评分中，联合管理组均低于对照组患者［（60.12±6.23）分 vs.（63.56±4.72）分，t=2.650，P=0.010，（66.49±5.67）分 vs.（72.41±5.25）分，t=4.600，P<0.001］。结论 医院-社区-患者慢病管理一体化路径能减少结直肠癌患者术后并发症、降低肠癌的复发和转移、提高生命质量并改善焦虑症状，对于结直肠癌术后患者的预后具有重要的价值。

关键词: 结直肠癌, 术后管理, 慢病管理, 一体化路径, 回顾性队列研究