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.

References

［1］马远征，王以朋，刘强，等．中国老年骨质疏松诊疗指南（2018）［J］．中国老年学杂志，2019，39（11）：2561-2579．DOI：10.3969/j.issn.1005-9202.2019.11.001.
MA Y Z，WANG Y P，LIU Q，et al．2018 China guideline for the diagnosis and treatment of senile osteoporosis［J］．Chinese Journal of Osteoporosis，2019，39（11）：2561-2579．DOI：10.3969/j.issn.1005-9202.2019.11.001.
［2］罗令，孙晓峰，皮丕喆，等．近10年来我国中老年人群骨质疏松症患病率的荟萃分析［J］．中国骨质疏松杂志，2018，24（11）：1415-1420．DOI：10.3969/j.issn.1006-7108.2018.11.005.
LUO L，SUN X F，PI P Z，et al．The prevalence of osteoporosis in Chinese middle aged and elderly population in recent 10 years：a meta analysis［J］．Chinese Journal of Osteoporosis，2018，24（11）：1415-1420．DOI：10.3969/j.issn.1006-7108.2018.11.005.
［3］张银萍，韦欢欢，夏茹意，等．女性骨质疏松症生活质量简易评价问卷的本土化研究［J］．护理研究，2015，29（34）：4245-4249．DOI：10.3969/j.issn.1009-6493.2015.34.008.
ZHANG Y P，WEI H H，XIA R Y，et al．A localization study on The Osteoporosis Assessment Questionnaire Short Version of female patients［J］．Chinese Nursing Research，2015，29（34）：4245-4249．DOI：10.3969/j.issn.1009-6493.2015.34.008.
［4］闫凤娟，王永晨，姜礼红.社区骨质疏松症的综合防治［J］．中国骨质疏松杂志，2019，25（4）：573-576．DOI：10.3969/j.issn.1006-7108.2019.04.030.
YAN F J，WANG Y C，JIANG L H.Comprehensive prevention and treatment of osteoporosis in the community［J］．Chinese Journal of Osteoporosis，2019，25（4）：573-576．DOI：10.3969/j.issn.1006-7108.2019.04.030.
［5］中国康复医学会，兰州大学循证医学中心，中国康复研究中心康复信息研究所，等.骨质疏松症康复指南（上）［J］．中国康复医学杂志，2019，34（11）：1265-1272．DOI：10.3969/j.issn.1001-1242.2019.11.001.
［6］中华医学会骨质疏松和骨矿盐疾病分会.中国骨质疏松症流行病学调查及“健康骨骼”专项行动结果发布［J］．中华骨质疏松和骨矿盐疾病杂志，2019，12（4）：317-318．DOI：10.3969/j.issn.1674-2591.2019.04.001.
［7］林树峰，李毅中.骨质疏松药物治疗率和依从性［J］．中国骨质疏松杂志，2020，26（3）：439-444．DOI：10.3969/j.issn.1006-7108.2020.03.028.
LIN S F，LI Y Z.The treatment rate and compliance of anti-osteoporosis drugs［J］．Chinese Journal of Osteoporosis，2020，26（3）：439-444．DOI：10.3969/j.issn.1006-7108.2020.03.028.
［8］WANG O，HU Y，GONG S，et al．A survey of outcomes and management of patients post fragility fractures in China［J］．Osteoporos Int，2015，26（11）：2631-2640．DOI：10.1007/s00198-015-3162-6.
［9］杨海苓，王萍，侯文秀，等．医院-社区-家庭三元联动延续护理平台的设计及应用［J］．中华护理杂志，2016，51（9）：1133-1137．DOI：10.3761/j.issn.0254-1769.2016.09.026.
YANG H L，WANG P，HOU W X，et al．Design and application of continuing care service platform under the linkage of hospital-community-family［J］．Chinese Journal of Nursing，2016，51（9）：1133-1137．DOI：10.3761/j.issn.0254-1769.2016.09.026.
［10］许玉洁，刘晓霞，张泓.高尿酸血症患者医院-社区-家庭一体化管理模式研究进展［J］．护理学杂志，2019，34（19）：99-101．DOI：10.3870/j.issn.1001-4152.2019.19.099.
XU Y J，LIU X X，ZHANG H.Hospital-community-family integrated management model on hyperuricemia：a literature review［J］．Journal of Nursing Science，2019，34（19）：99-101．DOI：10.3870/j.issn.1001-4152.2019.19.099.
［11］李祖毅，钟金，黄晓红.原发性骨质疏松症的诊治及防范［J］．医学信息，2014，27（36）：374．DOI：10.3969/j.issn.1006-1959.2014.36.573.
［12］胡梦皎.“医院-社区-家庭”一体化延伸护理用于老年糖尿病健康管理中的作用价值［J］．实用临床护理学电子杂志，2019，4（51）：173，180.
［13］李佳.基于“互联网+”的医院-社区一体化慢性病管理模式在老年高血压病人中的应用［J］．护理研究，2019，33（7）：1237-1240．DOI：10.12102/j.issn.1009-6493.2019.07.036.
LI J.Application of chronic disease management model of hospital community integration based on “Internet+” for elderly patients with hypertension［J］．Chinese Nursing Research，2019，33（7）：1237-1240．DOI：10.12102/j.issn.1009-6493.2019.07.036.
［14］李国宏，刘敏，张扬.医院社区一体化延续护理对慢性阻塞性肺疾病患者自我管理能力的影响［J］．中国护理管理，2017，17（12）：1648-1653．DOI：10.3969/j.issn.1672-1756.2017.12.016.
LI G H，LIU M，ZHANG Y.Effects of hospital-community integrated transitional care on self-management capability in patients with COPD［J］．Chinese Nursing Management，2017，17（12）：1648-1653．DOI：10.3969/j.issn.1672-1756.2017.12.016.
［15］KILIC A.Artificial intelligence and machine learning in cardiovascular health care［J］．Ann Thorac Surg，2020，109（5）：1323-1329．DOI：10.1016/j.athoracsur.2019.09.042.
［16］KHOSLA S，HOFBAUER L C.Osteoporosis treatment：recent developments and ongoing challenges［J］．Lancet Diabetes Endocrinol，2017，5（11）：898-907．DOI：10.1016/S2213-8587（17）30188-2.
［17］曹癸兰，梁静，陶宝明，等．医院-社区-家庭联动管理方案的制订及其在冠心病患者二级预防中的应用研究［J］．中华护理杂志，2018，53（10）：1157-1162．DOI：10.3761/j.issn.0254-1769.2018.10.001.
CAO G L，LIANG J，TAO B M，et al．Application of linkage management model in the secondary prevention of coronary heart disease［J］．Chinese Journal of Nursing，2018，53（10）：1157-1162．DOI：10.3761/j.issn.0254-1769.2018.10.001.
［18］刘芳，杨玲凤，李乐之，等．老年糖尿病患者医院-社区-家庭一体化互动管理模式建立与应用效果［J］．中国老年学杂志，2015，35（24）：7210-7212．DOI：10.3969/j.issn.1005-9202.2015.24.114.
［19］游利.骨质疏松症社区诊疗管理模式的探索［J］．上海预防医学，2017，29（12）：917-921．DOI：10.3969/j.issn.1004-9231.2017.12.004.
YOU L.Exploration on management mode for community diagnosis and treatment for osteoporosis［J］．Shanghai Journal of Preventive Medicine，2017，29（12）：917-921．DOI：10.3969/j.issn.1004-9231.2017.12.004.
［20］MENG J，SUN N，CHEN Y，et al．Artificial neural network optimizes self-examination of osteoporosis risk in women［J］．J Int Med Res，2019，47（7）：3088-3098．DOI：10.1177/0300060519850648.
［21］张宇，李姣.电子健康档案数据挖掘与整合技术新进展［J］．中国数字医学，2017，12（9）：41-44．DOI：10.3969/j.issn.1673-7571.2017.09.016.
ZHANG Y，LI J.New trends in electronic health record data mining and integration techniques［J］．China Digit Med，2017，12（9）：41-44．DOI：10.3969/j.issn.1673-7571.2017.09.016.
［22］WANG Y，ZHAO Y，THERNEAU T M，et al．Unsupervised machine learning for the discovery of latent disease clusters and patient subgroups using electronic health records［J］．J Biomed Inform，2020，102：103364．DOI：10.1016/j.jbi.2019.103364.
［23］MARTíN-MERINO E，HUERTA-áLVAREZ C，PRIETO-ALHAMBRA D，et al．Cessation rate of anti-osteoporosis treatments and risk factors in Spanish primary care settings：a population-based cohort analysis［J］．Arch Osteoporos，2017，12（1）：39．DOI：10.1007/s11657-017-0331-6.
［24］PROCTER S，WILSON P M，BROOKS F，et al．Success and failure in integrated models of nursing for long term conditions：multiple case studies of whole systems［J］．Int J Nurs Stud，2013，50（5）：632-643．DOI：10.1016/j.ijnurstu.2012.10.007.
［25］POPE L，DUBRAS L.Delivering medical education for future healthcare needs：a community-focused challenge［J］．Educ Prim Care，2020，31（5）：266-269．DOI：10.1080/14739879.2020.1767513.
［26］JANISZEWSKA M，BARANSKA A，JEDRYCH T，et al．The impact of selected factors on acceptance of illness and life satisfaction among female residents of rural areas treated for osteoporosis［J］．Ann Agric Environ Med，2019，26（4）：592-599．DOI：10.26444/aaem/109598.
［27］杜爽，刘冰，孙琳.骨质疏松症患者的健康宣教及护理干预［J］．中国医药指南，2019，17（20）：265-266.
［28］林巧旋，尤映彬，孙育欣，等．LEARNS健康教育模式在骨质疏松症患者中的应用［J］．齐鲁护理杂志，2020，26（6）：66-69．DOI：10.3969/j.issn.1006-7256.2020.06.021.
［29］赵庆，刘贤亮，牛淑珍，等．慢性病患者医院-社区联动延续护理质量指标的研究进展［J］．中华护理杂志，2018，53（11）：1386-1390．DOI：10.3761/j.issn.0254-1769.2018.11.022.
［30］王宗颖，乐嘉宜.家庭医生团队对社区中老年居民骨质疏松健康信念的干预效果研究［J］．护理研究，2019，33（16）：2866-2868．DOI：10.12102/j.issn.1009-6493.2019.16.030.
WANG Z Y，LE J Y.Intervention effect of family doctor team's knowledge attitude practice on the belief of osteoporosis among middle-aged and elderly residents in the community［J］．Chinese Nursing Research，2019，33（16）：2866-2868．DOI：10.12102/j.issn.1009-6493.2019.16.030.
［31］国务院.国务院关于印发“十三五”深化医药卫生体制改革规划的通知（国发〔2016〕78号）［EB/OL］．（2017-01-09）［2019-02-20］．http：//www.gov.cn/zhengce/content/2017-01/09/content_5158053.htm.
［32］李霞，常念欢.多学科管理模式对老年患者生活质量及预后的影响［J］．中华老年病研究电子杂志，2018，5（3）：33-36．DOI：10.3877/cma.j.issn.2095-8757.2018.03.007.
LI X，CHANG N H.The effect of multidisciplinary integrated treatment and management model on the quality of life and prognosis and medical management in the elderly［J］．Chinese Journal of Geriatics Research：Electron Ed，2018，5（3）：33-36．DOI：10.3877/cma.j.issn.2095-8757.2018.03.007.
［33］王粲霏，贾会英，吴珂，等．多学科协作模式在安宁疗护中的应用研究进展［J］．中华护理杂志，2018，53（7）：866-872．DOI：10.3761/j.issn.0254-1769.2018.07.020.

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