Current Situation and Prospect of Chronic Obstructive Pulmonary Disease Community Management in China

doi:10.12114/j.issn.1007-9572.2019.00.756

Abstract

Abstract: Chronic obstructive pulmonary disease（COPD） has been the third most common chronic disease in China，bringing heavy economy burden to us.However，the primary healthcare management of COPD is still limited，and great improvement is needed.For example，the early screening rate and diagnosis rate of COPD are low，health education is not in place，equipment and drugs are insufficient，drug use is not standard，and the diagnosis and treatment ability of community doctors is poor.In this review，we summarize the current status of the primary healthcare management of COPD，and expound the problems of the primary healthcare management of COPD，and put forward the possible better primary mode of healthcare management，such as general practitioner team management model，hospital-community-family-individual hierarchical diagnosis and treatment model，internet-based patient management model，in order to improve the prognosis and life quality of patients with COPD.

Key words: Pulmonary disease, chronic obstructive；Community management；Community medicine；Mode-exporing

摘要： 我国慢性阻塞性肺疾病（以下简称慢阻肺）人群庞大，已成为第三大常见慢性病，给患者家庭和社会带来了沉重的经济负担，然而我国社区基层医疗机构对慢阻肺的管理却存在明显短板，如早期筛查率、诊断率低下，健康宣教不到位，慢阻肺相关诊疗设备和药物匮乏，药物使用不规范，社区医生诊疗水平欠佳。本文通过对我国慢阻肺的社区管理现状进行综述，阐明目前我国慢阻肺社区管理存在的诸多问题，并对社区全科医生团队管理模式、医院-社区-家庭-个人分级诊疗模式、基于互联网的慢阻肺患者管理模式为基层医疗机构提供的更优质的慢阻肺管理办法进行展望，以期提高慢阻肺患者的预后和生活质量。

关键词: 肺疾病, 慢性阻塞性；社区管理；社区医学；模式探索

CHEN Mingmin,YE Kangli,XU Zhijie, et al. Current Situation and Prospect of Chronic Obstructive Pulmonary Disease Community Management in China　[J]. Chinese General Practice, 2020, 23(3): 251-256. DOI: 10.12114/j.issn.1007-9572.2019.00.756.
陈明敏,叶康丽,徐志杰等. 我国慢性阻塞性肺疾病社区管理现状与展望[J]. 中国全科医学, 2020, 23(3): 251-256. DOI: 10.12114/j.issn.1007-9572.2019.00.756.

References

［1］Global strategy for the diagnosis，management，and prevention of chronic obstructive lung disease，2018 report［EB/OL］．［2019-06-07］.http：//goldcopd.org/gold-reports/.
［2］易小均.浅谈基层医院药房管理存在问题及对策［J］．大家健康：下旬版，2015（2）:277-278．DOI:10.3969/j.issn.1009-6019.2015.02.364.
［3］WANG C，XU J Y，YANG L，et al．Prevalence and risk factors of chronic obstructive pulmonary disease in China（the China Pulmonary Health［CPH］ study）：a national cross-sectional study［J］．Lancet，2018，391（10131）：1706-1717．DOI:10.1016/S0140-6736（18）30841-9.
［4］冯淬灵，武维屏，徐丽英，等．北京城区社区医生对慢性阻塞性肺疾病的认知及管理状况调查［C］//第十一次全国中西医结合防治呼吸系统疾病学术研讨会论文集.北京，2010：254-257.
［5］DECRAMER M，MIRAVITLLES M，PRICE D，et al．New horizons in early stage COPD-improving knowledge，detection and treatment［J］．Respiratory Medicine，2011，105（11）：1576-1587．DOI：10.1016/j.rmed.2010.12.015.
［6］刘亚男，许文兵，孟淑珍，等．探究峰流速仪呼气峰流速检测对慢性阻塞性肺疾病的筛查效力［J］．中国呼吸与危重监护杂志，2015，14（3）：250-254．DOI:10.7507/1671-6205.2015062.
LIU Y N，XU W B，MENG S Z，et al．The effectiveness of peak flow meter in COPD screening［J］．Chinese Journal of Respiratory and Critical Care Medicine，2015，14（3）：250-254．DOI:10.7507/1671-6205.2015062.
［7］沈楚婕，张伟.慢性阻塞性肺疾病早期筛查方法及临床意义［J］．国际呼吸杂志，2015，35（15）：1144-1148．DOI:10.3760/cma.j.issn.1673-436X.2015.15.007.
SHEN C J，ZHANG W.Feasible methods and the clinical meaning of early detection for chronic obstructive pulmonary disease［J］．International Journal of Respiration，2015，35（15）：1144-1148．DOI:10.3760/cma.j.issn.1673-436X.2015.15.007.
［8］尹宝伶.COPD筛查问卷与肺功能检查诊断COPD的相关性研究［D］．北京：北京中医药大学，2013.
［9］刘妍，邓笑伟.筛查问卷与肺功能检查在慢性阻塞性肺疾病早期诊断中的研究［J］．临床肺科杂志，2015，20（3）：500-503．DOI:10.3969/j.issn.1009-6663.2015.03.038.
LIU Y，DENG X W.Study of screening questionnaire and pulmonary function test in the early diagnosis of COPD［J］．Journal of Clinical Pulmonary Medicine，2015，20（3）：500-503．DOI:10.3969/j.issn.1009-6663.2015.03.038.
［10］许扬，张鹏俊，杨汀，等．我国基层慢性阻塞性肺疾病防治现状研究［J］．中国全科医学，2016，19（34）：4153-4158．DOI:10.3969/j.issn.1007-9572.2016.34.001.
XU Y，ZHANG P J，YANG T，et al．Current status of prevention and control of chronic obstructive pulmonary disease in primary care in China［J］．Chinese General Practice，2016，19（34）：4153-4158．DOI:10.3969/j.issn.1007-9572.2016.34.001.
［11］何权瀛.我国农村基层慢性阻塞性肺疾病诊治现状调查报告［J］．中国呼吸与危重监护杂志，2014，13（1）：5-9．DOI:10.7507/1671-6205.2014002.
HE Q Y.Current situation of diagnosis and treatment of COPD in rural primary hospitals of China［J］．Chinese Journal of Respiratory and Critical Care Medicine，2014，13（1）：5-9．DOI:10.7507/1671-6205.2014002.
［12］上海市医学会呼吸分会基层呼吸疾病防治联盟.上海市社区医生肺功能知识问卷调查［J］．中国呼吸与危重监护杂志，2018，17（2）：165-168．DOI:10.7507/1671-6205.201706007.
［13］甘文云，赵兵，李海明，等．关于豫南地区内科医师对慢性阻塞性肺疾病诊疗行为的调查［J］．中国临床医学，2015，22（5）：604-606.
GAN W Y，ZHAO B，LI H M，et al．Research on diagnosis and treatment behavior for chronic obstructive disease among physicians of South HenanArea［J］．Chinese Journal of Clinical Medicine，2015，22（5）：604-606.
［14］何剑.云南省某县内科医师对呼吸系统常见病诊治认知调查［J］．南昌大学学报:医学版，2013，53（3）：68-71．DOI:10.3969/j.issn.1000-2294.2013.03.020.
HE J.Physicians' cognition with diagnosis and treatment of common respiratory diseases in a County of Yunnan Province［J］．Journal of Nanchang University（Medical Science），2013，53（3）：68-71．DOI:10.3969/j.issn.1000-2294.2013.03.020.
［15］纪春东，于秀芹，柴景伟，等．辽宁阜新地区慢性阻塞性肺疾病患者认知和诊疗现状分析［J］．中国继续医学教育，2015，7（21）：15-16．DOI:10.3969/j.issn.1674-9308.2015.21.011.
JI C D，YU X Q，CHAI J W，et al．Analysis of the status of cognition and diagnosis for chronic obstructive pulmonary disease（COPD） in Liaoning Fuxin［J］．China Continuing Medical Education，2015，7（21）：15-16．DOI:10.3969/j.issn.1674-9308.2015.21.011.
［16］陈婧瑜，林修全，章叶发，等．福建省40岁及以上居民慢性阻塞性肺疾病认知现状分析［J］．慢性病学杂志，2019，20（3）：347-350．DOI:10.16440/j.cnki.1674-8166.2019.03.011.
CHEN J Y，LIN X Q，ZHANG Y F，et al．Analysis of knowledge status about chronic obstructive pulmonary disease in residents aged 40 years and over in Fujian Province［J］．Chronic Pathematology Journal，2019，20（3）：347-350．DOI:10.16440/j.cnki.1674-8166.2019.03.011.
［17］顾丹，朱兰.上海市徐汇区全科医师及居民慢性阻塞性肺疾病认知程度调查［J］．中国医学工程，2015，23（11）：64-65.
［18］徐丽英.北京城区社区医生对慢性阻塞性肺疾病的认知程度及管理现状的调查研究［D］．北京：北京中医药大学，2011.
XU L Y.The investigation on cognitive degree of knowledge and the conditions of community management of chronic obstructive pulmonary disease by community physicians［D］．Beijing：Beijing University of Chinese Medicine，2011.
［19］罗勇.基层防控慢阻肺哪些难题待解［N］．健康报，2013-02-18（8）.
［20］徐宝龙，于莉靓.某区基层医疗机构慢阻肺的防控状况调查［J］．中国医药指南，2017，15（25）：297-299．DOI:10.15912/j.cnki.gocm.2017.25.242.
XU B L，YU L J.Chronic obstructive pulmonary disease in the prevention and control status of primary medical institutions in a district［J］．Guide of China Medicine，2017，15（25）：297-299．DOI:10.15912/j.cnki.gocm.2017.25.242.
［21］中华医学会呼吸病学分会慢性阻塞性肺疾病学组.慢性阻塞性肺疾病诊治指南（2007年修订版）［J］．中华内科杂志，2007，46（3）：254-261．DOI:10.3760/j.issn:0578-1426.2007.03.031.
［22］周恩飞，罗勇，徐卫国，等．上海市郊县基层医生慢性阻塞性肺疾病规范诊疗知晓情况调查［J］．临床误诊误治，2010，23（1）：9-11．DOI:10.3969/j.issn.1002-3429.2010.01.005.
ZHOU E F，LUO Y，XU W G，et al．Standardized treatment and management of COPD（a questionaire by local physicians in Shanghai suburban areas）［J］．Clinical Misdiagnosis & Mistherapy，2010，23（1）：9-11．DOI:10.3969/j.issn.1002-3429.2010.01.005.
［23］张爱荣.乡镇医院内科医生对慢性阻塞性肺疾病治疗现状的分析［J］．中国农村卫生，2015（19）：62-63.
［24］庞红燕，杨汀，王辰.2016年更新版GOLD慢性阻塞性肺疾病诊断、治疗和预防的全球策略简介［J］．中国医学前沿杂志:电子版，2016，8（7）：28-32．DOI:10.3969/j.issn.1674-7372.2016.07.007.
［25］HOLLAND A E，MAHAL A，HILL C J，et al．Home-based rehabilitation for COPD using minimal resources：a randomised，controlled equivalence trial［J］．Thorax，2017，72（1）：57-65．DOI:10.1136/thoraxjnl-2016-208514.
［26］张荣葆，何权瀛.基层医生对慢性阻塞性肺疾病相关知识的认知情况［J］．中国慢性病预防与控制，2009，17（1）：61-63．DOI:10.16386/j.cjpccd.issn.1004-6194.2009.01.022.
ZHANG R B，HE Q Y.Awareness of knowledge of COPD by doctors in district and community hospitals［J］．Chinese Journal of Prevention and Control of Chronic Non-Communicable Diseases，2009，17（1）：61-63．DOI:10.16386/j.cjpccd.issn.1004-6194.2009.01.022.
［27］杨明，迟春花.英国慢性阻塞性肺疾病的社区综合防治［J］．中华全科医师杂志，2017，16（8）：650-653．DOI:10.3760/cma.j.issn.1671-7368.2017.08.023.
YANG M，CHI C H.Comprehensive prevention and management of chronic obstructive pulmonary disease in primary care in UK［J］．Chinese Journal of General Practitioners，2017，16（8）：650-653．DOI:10.3760/cma.j.issn.1671-7368.2017.08.023.
［28］杨多华，陈亮，奚晴超，等．全科团队管理模式对郊区老年慢阻肺稳定期患者干预效果评价［J］．临床肺科杂志，2016，21（10）：1811-1813，1814．DOI:10.3969/j.issn.1009-6663.2016.10.020.
YANG D H，CHEN L，XI Q C，et al．Evaluation of general team management mode suburb intervention in elderly patients with chronic obstruc-tive pulmonary disease at stable phase［J］．Journal of Clinical Pulmonary Medicine，2016，21（10）：1811-1813，1814．DOI:10.3969/j.issn.1009-6663.2016.10.020.
［29］张湘燕，余红，刘维佳，等．社区慢性阻塞性肺疾病管理研究［J］．贵州医药，2015，39（12）：1071-1076．DOI:10.3969/j.ISSN.1000-744X.2015.12.005.
ZHANG X Y，YU H，LIU W J，et al．Study on the community management of chronic obstructive pulmonary disease-Based on the example of urban and rural areas in Guizhou Province［J］．Guizhou Medical Journal，2015，39（12）：1071-1076．DOI:10.3969/j.ISSN.1000-744X.2015.12.005.
［30］潘倩倩，蔡仁萍，潘迪飞，等．基于医院-社区-家庭-个人的慢性阻塞性肺疾病慢病管理模式探讨［J］．中国卫生产业，2018，15（30）：55-57．DOI:10.16659/j.cnki.1672-5654.2018.30.055.
［31］熊波，简铭，王晓明，等．基于医院-社区-家庭-个人的慢阻肺慢病管理模式探讨［J］．中国社区医师，2017，33（21）：6-7．DOI:10.3969/j.issn.1007-614x.2017.21.2.
XIONG B，JIAN M，WANG X M，et al．Study on management mode of COPD based on hospital-community-family-individual［J］．Chinese Community Doctors，2017，33（21）：6-7．DOI:10.3969/j.issn.1007-614x.2017.21.2.
［32］虞芬.基于网络的社区慢阻肺患者自我管理平台模块内容的构建研究［D］．南昌：南昌大学，2018.
［33］叶亮，张静，史莹，等.基于紧密型医联体的慢阻肺社区防治网络体系建立的临床应用研究［J/OL］．临床肺科杂志，2019（10）:1755-1759.［2019-06-07］．https://kns-cnki-net.ssl.hznu.edu.cn/kcms/detail/34.1230.R.20190923.2044.006.html.
［34］胡琴，谢作舟，刘漪，等．基于信息平台的慢阻肺患者自我管理模式构建及效果评价［J］．昆明医科大学学报，2018，39（9）:43-47.
HU Q，XIE Z Z，LIU Y，et al．The construction and evaluation of self management mode for patient with chronic obstructive pulmonary disease on the basis of information platform［J］．Journal of Kunming Medical University，2018，39（9）:43-47.
［35］宁婕，吴艳平，李玉凤.我国糖尿病肾脏疾病社区管理现状与探索［J］．中国全科医学，2019，22（4）：402-406.
NING J，WU Y P，LI Y F.Community-based diabetic kidney disease management in China：current status and progressive development exploration［J］．Chinese General Practice，2019，22（4）：402-406.

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