Hospital-community-home Integrated Management Path for Patients with Osteoporosis：Exploratory Analysis and Insights to Primary Care

doi:10.12114/j.issn.1007-9572.2021.00.431

Abstract

Abstract: Osteoporosis prevalence is increasing with rapid acceleration of aging，which is the fifth major common chronic disease，easily leading to serious outcomes，such as brittle fracture，disability，and even death.The prevalence rate of osteoporosis in Chinese people aged over 60 is 36%.It is predicted that by 2050，the numbers of Chinese people suffering from osteoporosis and osteoporotic fractures will be 202 million，and 6 million，respectively，which will impose a serious burden on society and families.So it is essential to carry out effective systematic management of osteoporosis.We introduced the definition of hospital-community-home integrated management，and explained the necessity of using it in osteoporosis management，and interpreted the development of path of hospital-community-home integrated osteoporosis management，which is composed of five aspects：building a multidisciplinary management team for osteoporosis，constructing an online osteoporosis health management platform，modifying the management of osteoporosis patients' health records，strengthening osteoporosis-related trainings for general practitioner teams，and strengthening osteoporosis-related health education for osteoporosis patients and their families.We consider this path to be feasible for osteoporosis management，and for the building of an efficient and standardized osteoporosis management mode，to cope with the rapid growth of osteoporosis prevalence in China.

Key words: Osteoporosis, Hospital-community-family integrated management, Disciplinary collaboration, Internet platform

摘要： 随着我国人口老龄化进程的加快，骨质疏松症的患病率逐年上升，已位居常见慢性病的第5位。骨质疏松症易导致脆性骨折、残疾甚至死亡等严重后果。目前我国60岁以上人群骨质疏松症患病率为36%，预计到2050年，我国骨质疏松症患者将达到2.02亿人，骨质疏松性骨折患者将达600万人，将给社会和患者家庭带来沉重的经济负担，因此如何有效地开展骨质疏松症系统化管理显得尤为重要。本文介绍了医院-社区-家庭一体化管理的概念及将其应用在骨质疏松症管理中的必要性，分别从组建多学科协作管理团队、构建互联网在线健康管理平台、健全患者健康档案、加强全科医生团队专科知识培训、加强患者及其家属的宣传教育五个方面阐述了如何构建骨质疏松症医院-社区-家庭一体化管理路径，指出将医院-社区-家庭一体化管理路径应用在骨质疏松症管理中切实可行，可建立高效、规范的骨质疏松症管理模式，以应对我国骨质疏松症患病率快速增长的现状。

关键词: 骨质疏松症, 医院-社区-家庭一体化管理, 学科协作, 互联网平台

CAI Yaoting,FANG Ronghua. Hospital-community-home Integrated Management Path for Patients with Osteoporosis：Exploratory Analysis and Insights to Primary Care　[J]. Chinese General Practice, 2021, 24(15): 1938-1942. DOI: 10.12114/j.issn.1007-9572.2021.00.431.
蔡耀婷,方荣华. 骨质疏松症患者医院-社区-家庭一体化管理路径探究及对基层医疗的启示[J]. 中国全科医学, 2021, 24(15): 1938-1942. DOI: 10.12114/j.issn.1007-9572.2021.00.431.

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