Abstract: Background　Osteoarthritis is the third leading chronic disease in older people. There are quite a lot of osteoarthritis sufferers，and a large number of people at high risk for osteoarthritis. However，due to lack of research on standardized community-based diagnosis and treatment of osteoarthritis，and a complete，scientific process regarding standardized community-based management of osteoarthritis，long-term management of osteoarthritis is still not accessible in the community. Objective　To develop a complete，practical standardized process for community-based osteoarthritis prevention and treatment with integrated traditional Chinese and western medicine（hereinafter referred to as "osteoarthritis prevention and treatment process"） with a detailed analysis of the major technical points and difficulties. Methods　The osteoarthritis prevention and treatment process was developed from March to December 2020，which consists of preparatory，development and informatization stages. In the preparatory stage，literature review，investigation approach，and group discussion were used to develop a literature database including guidelines/standards on osteoarthritis prevention and treatment，and the aspects and services involved in the prevention and treatment process were determined. In the development stage，the standard operating procedure（SOP） for osteoarthritis prevention and treatment was updated from version 1.0 to version 4.0 in accordance with a two-round group discussion and focus group discussion，as well as the results of the pilot implementation of the osteoarthritis prevention and treatment process. In the informatization stage，based on the literature database formed in the preparatory stage，and SOP 4.0，a database of indicators involved in the osteoarthritis prevention and treatment process was developed，and used for further informatizing the process. Results　In the preparatory stage，10 eligible guidelines/standards were included. The determined osteoarthritis prevention and control process consists of five aspects〔community mobilization，evaluation（screening），diagnosis，intervention and follow-up〕，with a focus on community mobilization，evaluation（screening），and follow-up. In the development stage，the developed SOP 4.0 for osteoarthritis prevention and treatment includes 10 items: service population，service time，settings，must-have service tools，providers，must-have professional skills of providers，service profile（list），service spending（cost），the generated data list，and evidence-based basis for operation. And the complete prevention and control process was formed. In the informatization stage，a table of the structure of the above-mentioned five aspects was presented. Conclusion　Our osteoarthritis prevention and treatment process could guide community healthcare workers to deliver osteoarthritis prevention and treatment services using available community resources to all the people in the local community. Our development process may be used as a reference for other community health institutions to develop the prevention and treatment pathway of osteoarthritis or other single diseases according to their own conditions.

Key words: Osteoarthritis, Community health services, Standardized process, Integrated traditional Chinese and western medicine

摘要： 背景　骨关节炎是老年人群的第三大常见慢性病，患病人群和高危人群基数均较大。目前，尚缺乏关于社区骨关节炎规范化防治的研究，社区内仍未形成完整、科学的骨关节炎标准化服务流程，使得骨关节炎长期健康管理服务无法提供。目的　开发出一套完整的、可实际应用的“社区骨关节炎中西医结合标准化防治流程”（简称“防治流程”），并详细分析开发过程中的技术要点及难点。方法　于2020年3—12月，分3个阶段开展“防治流程”的开发，包括筹备阶段、开发阶段、信息化阶段。筹备阶段，主要采用文献回顾法、调查法、小组讨论法，形成与骨关节炎防治相关的指南/标准类文献库，并确定“防治流程”涉及的环节、服务范围等。开发阶段，经多轮小组讨论、焦点小组访谈，并结合试运行情况，完成标准操作流程（SOP）1.0至SOP 4.0的不断修订、完善。信息化阶段，以筹备阶段检索到的数据库和SOP 4.0为依据，梳理出“防治流程”中涉及的指标数据库，为进一步信息化开发做好准备。结果　筹备阶段，共纳入符合要求的指南/标准类文献10篇，确定的“防治流程”涉及社区动员、评估（筛查）、诊断、干预、跟踪随访5个环节，以社区动员、评估（筛查）、跟踪随访3个环节为开发重点。开发阶段，形成的SOP 4.0包括服务对象、服务时间、服务地点、服务所需工具、服务人员、服务所需技能、对应服务内容（清单）、所涉服务费用（成本）、生成数据清单、本条操作循证依据共10项内容，形成了完整版“防治流程”。信息化阶段，整理出涉及上述5个环节的数据结构表。结论　本研究开发的“防治流程”可指导社区医务人员基于社区现有资源完成整个社区人群的骨关节炎防治工作，报告的开发流程可以为同行开展骨关节炎及其他单病种社区防治单元建设提供参考。

关键词: 骨关节炎, 社区卫生服务, 标准化流程, 中西医结合