Osteoarthritis has a high rate of disability and deformity, and can be combined with several physical and mental diseases. However, the early symptoms of the disease are not obvious. At present, there are problems in the management of osteoarthritis in the community such as uncoordinated management, inadequate methods and imperfect systems.

To construct and evaluate an informatics-based multidisciplinary management model for osteoarthritis patients in community, to promote the management of community osteoarthritis patients and improve the prognosis of the patients.

First a multidisciplinary management model of osteoarthritis patients in the community was constructed, including hierarchical management process of patients based on risk factor stratification, the multidisciplinary management team and its division of diagnosis and treatment, then an informatics based multidisciplinary management process was constructed, and information software development was completed. From July 2019 to July 2020, 80 patients with knee osteoarthritis who attended the general outpatient clinics of Dinghai and Daqiao Community Health Service Centers in Shanghai, and the orthopedics outpatient clinics of Yangpu District Central Hospital were randomly assigned into multidisciplinary management groups and general management group, with 40 patients in each group. The patients in general group were given conventional treatment, while the patients in multidisciplinary group were adopted information-based multidisciplinary management. Visual analogue scale (VAS) scores, Western Ontario McMaster University (WOMAC) osteoarthritis index score, the simplified scale of Arthritis Quality Of Life Measurement Scale (AIMS2) scores, Health Literacy Management Scale (HeLMS) scores, and body mass index (BMI) were assessed before and after 12 weeks of management, respectively.

Before treatment, there were no significant differences in VAS score, WOMAC osteoarthritis index score, AIMS2 score, Helms score, and BMI between patients with knee osteoarthritis in the multidisciplinary and general groups (P>0.05) . After 12 weeks of treatment, the VAS and WOMAC score of both the multidisciplinary and general groups went down, and the health literacy AIMS2 scores and Helms total score were higher after treatment than those before. The difference was statistically significant (P<0.05) . After 12 weeks of treatment, the AIMS2 total score and Helms total score of patients in the multidisciplinary group were higher than those in the general group, and the VAS score, WOMAC osteoarthritis index, and BMI were lower than those in the general group, with significant differences (P<0.05) .

The implementation of an informatics based community multidisciplinary management model for patients with osteoarthritis of the knee can effectively reduce the patients' joint pain and control their weight, improve their ability of daily living and health literacy, improve the quality of life of patients, and delay the progress of the disease.

骨关节炎致残、致畸率高，可合并多种身心疾病，但早期症状不明显。当前社区骨关节炎的管理存在管治不协调、方法不健全、制度不完善等问题。

构建并评价基于信息化的社区骨关节炎多学科管理模式，以促进对社区骨关节炎患者的管理，改善患者疾病预后。

首先构建社区骨关节炎患者的多学科管理模式，包含基于危险因素分层的患者分级管理流程、多学科管理团队及其诊治分工，然后构建基于信息化的多学科管理流程，并完成信息软件开发。选取2019年7月至2020年7月在上海市定海、大桥社区卫生服务中心全科门诊，以及杨浦区中心医院骨科门诊就诊的膝骨关节炎患者80例为研究对象，采用随机数表法将其分为普通组和多学科组，各40例。普通组采用常规治疗模式，多学科组在此基础上进行基于信息化的多学科管理。分别于治疗前和治疗12周后评估两组患者的视觉模拟评分法（VAS）评分、西安大略麦克马斯特大学（WOMAC）骨关节炎指数、关节炎生活质量测量量表（AIMS2）评分、健康素养管理量表（HeLMS）评分、体质指数（BMI）。

治疗前，多学科组和普通组膝骨关节炎患者的VAS评分、WOMAC骨关节炎指数、AIMS2评分、HeLMS评分、BMI比较，差异均无统计学意义（P>0.05）；治疗12周后，多学科组和普通组膝骨关节炎患者的VAS评分、WOMAC骨关节炎指数低于治疗前，AIMS2总分、HeLMS总分高于治疗前，差异有统计学意义（P<0.05）；治疗12周后，多学科组患者AIMS2总分、HeLMS总分高于普通组，VAS评分、WOMAC骨关节炎指数、BMI均低于普通组，差异有统计学意义（P<0.05）。

对膝骨关节炎患者实施基于信息化的社区骨关节炎患者多学科管理模式，可有效减轻患者的关节疼痛和体质量，提高患者的日常生活能力和健康素养，改善患者的生活质量，延缓患者的病情进展。