Abstract: Background　Evidence-based，high-quality and clinically applicable high-level health service is one of the important promoters to achieve the reform goals of improving people's health and patients' medical experience，as well as the efficiency of health services. With the promotion of contracted family doctor services，it is very important to assess the quality of such services for patients with chronic diseases. However，there is a lack of relevant criteria and assessment indices in China although there are various foreign criteria and systems for chronic disease management. Objective　To develop hypertension and diabetes health management quality indicators in China's primary care based on the experience of the US and the UK，and assess their applicability in Chengdu's Wuhou District. Methods　Based on the relevant contents of NHS-QOF，NCQA-PCMH and China basic public service specification，the first draft of "two diseases" health management quality index system is constructed. From December 2018 to June 2019，26 experts were invited to conduct two rounds of correspondence by Delphi method to form the final draft of the index system. The consensus index system is applied to the residents' health archives center of Wuhou District，the relevant population data are extracted according to the index definition，and the problems or barriers directly identified in the test process were analyzed，as well as the impact of the index system on the service quality of the contracted service team of family doctors. Results　The response rate，authority coefficients and Kendall's W were 100.0%（14/14），0.772，0.609（χ2=87.039，P<0.001），respectively，for the first round of expert consultation regarding hypertension management quality indicators in primary care，and were 87.5%（7/8），0.838，0.298（χ2=37.522，P<0.001），respectively，for the second round. The response rate，authority coefficients and Kendall's W were 100.0%（16/16），0.781，0.513（χ2=69.312，P<0.001），respectively，for the first round of expert consultation regarding diabetes management quality indicators in primary care，and were 87.5%（7/8），0.848，and 0.688（χ2=48.181，P<0.001）respectively，for the second round. Finally，a hypertension management quality system with three domains and 14 indicators，and a diabetes management quality system with three domains and 11 indicators，used for assessing family doctor services for hypertension and diabetes in primary care were developed. In terms of extracting data，we can directly extract the information used for 13 indicators. As the reading values of blood pressure are obtained by the monitoring of equipment，the accuracy of blood pressure needs to be further verified. For 12 indicators can not be extracted directly，we obtain five of them through improving the information system，and obtain other seven through other means of investigation. At the same time，the verification and application of monitoring indicators in Wuhou District has improved the family doctor's chronic disease management ability，and the chronic disease management has changed from process management to result management. Conclusion　There is no obvious cognitive difference between domestic experts on hypertension and diabetes management quality indicators in primary care. The information for most of indicators can be directly fetched and used for monitoring，feedback and assessment in the areas with residents' health records center. The application effect of the monitoring indicators is obvious.

Key words: Family doctor, Health management, Delphi method, Quality monitoring, Diabetes, Hypertension

摘要： 背景　循证、优质、适宜临床的高水平卫生服务是实现改善人民健康和患者就医体验、提高卫生服务效率等改革目标的重要推手之一。随着家庭医生签约服务的推行，监测慢性病患者家庭医生签约服务的质量越来越重要。虽然国际上有多种慢性病管理规范及指标体系，但我国家庭医生签约服务的规范及监测指标仍然缺乏。目的　借鉴英、美标准构建高血压和糖尿病（简称“两病”）健康管理在基层医疗卫生服务中的质量指标，并评价其在成都市武侯区的应用可行性。方法　基于英国国家医疗服务体系的质量与效果框架（NHS-QOF）、美国国家质量保证委员会的以患者为中心的家庭式医疗模式（NCQA-PCMH）、中国基公服规范中的相关内容，构建“两病”健康管理质量指标体系初稿。于2018年12月至2019年6月采用德尔菲法邀请26例专家开展两轮函询，形成指标体系终稿。将形成共识的指标体系应用于武侯区居民健康档案中心，根据指标定义提取相关人群数据，分析在直接形成监测数据的应用过程中的问题和障碍，以及指标体系对家庭医生签约服务团队服务质量的影响。结果　高血压两轮专家咨询表回收率分别为100.0%（14/14）和87.5%（7/8），两轮咨询专家的权威系数为0.772和0.838；糖尿病两轮专家咨询表回收率分别为100.0%（16/16）和87.5%（7/8），两轮咨询专家的权威系数为0.781和0.848。针对高血压的两轮专家咨询的肯德尔协调系数分别为0.609（χ2=87.039，P<0.001）和0.298（χ2=37.522，P<0.001），针对糖尿病的分别为0.513（χ2=69.312，P<0.001）和0.688（χ2=48.181，P<0.001）。最终构建了“两病”6个一级指标、25个二级指标的慢性病患者家庭医生签约服务质量监测指标。在提取数据过程中，13个指标可直接提取，但血压值因无法直接从血压检测设备上提取，其监测真实性需要进一步验证；12个指标不可直接提取，其中5个可通过改造信息系统提取，7个需通过其他调查手段获得。监测指标在武侯区的验证运用结果显示其提高了家庭医生慢性病管理能力，使慢性病管理从过程管理向结果管理转变。结论　国内专家对“两病”患者的健康管理质量监测指标未存在明显的认知差异。在建立有居民健康档案中心的区域，大部分指标可直接抓取后用于监测、反馈和考核，指标体系应用效果明显。

关键词: 家庭医生, 健康管理, 德尔菲法, 质量监测指标, 糖尿病, 高血压