Currently, scholars in China are exploring chronic disease management models based on treatment-prevention integration, however, the quantitative evaluation researches are scarce and in the initial stage, lacking in relevance and timeliness.

To construct the on-site evaluation index system for integration of medical and preventive services for chronic diseases in primary health care institutions and provide a reference for the quality improvement of integration of medical and preventive services.

The on-site evaluation index system for integration of medical and preventive services for chronic diseases in primary health care institutions was initially constructed by literature review, policy induction and expert interview. From June to August 2022, two rounds of expert consultation with 17 experts were conducted using the Delphi method, the index system was determined according to the results of expert consultation, and the weight of each index was calculated by using the analytic hierarchy process.

The on-site evaluation index system for integration of medical and preventive services for chronic diseases in primary health care institutions was initially constructed consisting of 5 primary indexes, 12 secondary indexes and 37 tertiary indexes. The effective questionnaire recovery rate of the two rounds of expert consultation was 100.0% with the expert authority coefficient of 0.81; the Kendall coordination coefficients of the importance of the three levels of indexes were 0.239 (χ²=8.76, P<0.05) and 0.275 (χ²=4.15, P<0.05) , the Kendall coordination coefficients of the feasibility of the three levels of indexes were 0.234 (χ²=19.63, P<0.05) and 0.248 (χ²=12.43, P<0.05) . The on-site evaluation index system for integration of medical and preventive services for chronic diseases in primary health care institutions was finally constructed consisting of 5 primary indexes, 12 secondary indexes and 40 tertiary indexes, the weight of the five primary indicators was 0.200 0.

The evaluation index system has a certain practical guidance for the improvement of the capacity of integration of medical and preventive services for chronic diseases in urban and rural community health service institutions. However, the evaluation index system should also be dynamically adjusted according to the specific situation to effectively reflect the quality of integration of medical and preventive services for chronic diseases in primary health care institutions.

当前我国学者不断探索基于医防融合的慢性病管理模式，但其量化评估研究匮乏，缺乏针对性和时效性，尚处于初级阶段。

构建基层医疗卫生机构慢性病医防融合服务质量现场评价指标体系，为基层医疗卫生机构慢性病医防融合服务质量提升提供参考依据。

通过文献分析法、政策归纳法、专家访谈法初步构建基层医疗卫生机构慢性病医防融合服务质量现场评价指标体系。于2022年6—8月，运用德尔菲法对17名专家进行两轮专家咨询，根据专家咨询结果确定指标体系，运用层次分析法计算各指标权重。

初步构建的基层医疗卫生机构慢性病医防融合服务质量现场评价指标体系由5个一级指标、12个二级指标、37个三级指标组成。两轮专家咨询的问卷有效回收率均为100.0%；专家权威系数为0.81；三级指标重要性的肯德尔协调系数分别为0.239（χ²=8.76，P<0.05）、0.275（χ²=4.15，P<0.05），三级指标可行性的肯德尔协调系数分别为0.234（χ²=19.63，P<0.05）、0.248（χ²=12.43，P<0.05）。最终形成包括5个一级指标、12个二级指标、40个三级指标的基层医疗卫生机构慢性病医防融合服务质量现场评价指标体系，5个一级指标的权重均为0.200 0。

本评价指标体系对城乡社区卫生服务机构提升医防融合服务能力具有一定的现实指导意义，但也要视具体情况对评价指标体系进行动态调整，以使其能够切实反映基层医疗卫生机构慢性病医防融合服务质量状况。