基于初级卫生保健5C理念的社区多重慢病管理：全科医生团队签约服务人群队列研究

Multimorbidity (≥2 chronic conditions within an individual) has become a growing concern worldwide in the recent years. Evidence from an earlier research in the epidemiology of multimorbidity in Chinese population led by the principal applicant has shown that existing specialist-care model cannot fully address the health care need rising from health promotion, disease prevention, appropriate treatment, and community-based rehabilitation. This project aims to conduct a multi-centre prospective cohort study with primary care delivered by general practitioner (GP)-team contracted service in the community. A Mandarin Chinese version of the Primary Care Assessment Tool (PCAT) previously validated by the principal applicant will be adopted to evaluate the process of care from patients’ experiences with regard to 5C’s primary care core attributes, i.e., first-contact care, continuity of care, coordination of care, comprehensiveness of care, and community-oriented care. This will be modelled with the longitudinal outcome of care using multivariate regression approach for quantifiable association analysis in response to research questions in the arena of health service management. This project is expected to establish and reveal the association between primary care’s five core attributes in process of care and health outcome including clinical parameters, disease treatment burden, and long-term disease risk (with cardiovascular event which is the leading cause of death as an example) among both multimorbid subjects and those who are at high risk of developing multimorbidity. The evidence-based nature of this project shall generate results for informing policy in terms of guiding the evaluation of GP-led disease management and establishing a proper primary care system for integrating the prevention and control of multimorbidity.

多重慢病(即同时患有2种或以上慢性疾患)是近年来国内外新兴热点。研究团队前期对我国社区人群开展的多重慢病流行病学横断面研究表明，现有分专科诊疗模式不能应对健康促进、预防保健、合理治疗及社区康复等需求。本项目拟基于多中心社区前瞻性人群队列，实施全科医生团队签约式服务下的社区多重慢病管理，利用前期验证的初级卫生保健评价工具PCAT，从初级卫生保健5C核心特征指标角度(社区首诊、持续性、协调性、综合性、社区导向性)量化评价服务提供的过程质量，并结合多重慢病管理效果建立以回归分析为基础的纵向关联模型(创新点)，为解决卫生管理学科学问题提供量化依据。本项目有望揭示社区全科医生团队签约服务提供过程的关键环节与多重慢病患者及多重慢病高危群体的生物医学指标、疾病治疗负担、不良疾病风险等宏观效果的纵向量化关联，从而可为引导和考核全科医生健康管理服务，建立社区多重慢病防治结合的适宜管理体系提供充分的科学依据。

多重慢病（即同时患有2种或以上慢性疾患）是近年来国内外新兴热点。本项目运用回顾性研究结合前瞻性研究手段，掌握了社区多重慢病及多重慢病高危风险人群的卫生服务及防治现状等资料；以初级卫生保健的5个核心量化特征为切入点，基于初级卫生保健评价工具条目，形成全科医生团队签约服务下的社区多重慢病管理服务包规范标准；在初级卫生保健评价工具（PCAT）问卷基础上，获取人口社会学特征、患者卫生服务利用情况、医疗付费及因病住院情况、慢性疾病谱、疾病家族史、生活及膳食方式、服用药物依从性、多重慢病负担指数、临床指标等资料；通过首诊性（first contact）、持续性（continuity）、协作性（coordination）、综合性（comprehensiveness）、面向家庭及社区性（family-centredness and community orientation）等患者实际接受服务的五个方面，利用统计学分析模型对社区多重慢病管理过程进行量化分析，得出回归模型指标关联程度的主要参数。研究发现在签约服务协作性方面，构建慢性病健康管理小组有助于提高患者的服务依从性，有助于改善生理生化指标及代谢水平；在签约服务连续性方面，较大年龄者（aOR=0.87, P<0.001）、男性（aOR=0.50, P=0.043）、教育程度较低者（aOR=0.34, P=0.002）的健康指标持续改善的可能性较低；每周体育锻炼不足1次（aOR=0.699, P=0.037）、每日饮酒1次或以上（aOR=0.500, P=0.038）者，健康指标持续改善的可能性也较低。研究对包括基本医疗、疾病预防、生活方式监测、慢病防治管理在内的社区全科医生团队签约服务包进行了初级卫生保健核心特征评价，回归模型参数表明签约的多重慢病患者比未签约者PCAT评价分数高2.468分（P<0.001），近3年有住院者比未住院者PCAT评价分数高1.703分（P=0.001）；多重慢病患者自我健康状况评价每降低一个分数等级，PCAT评价分数低2.243分（P<0.001），治疗负担评价每增加一个分数等级，PCAT评价分数低0.262分（P<0.001）。本项目通过中文核心期刊及SCI期刊论文、国内外学术会议及研讨口头报告及白皮书等多种方式进行成果传播交流，为完善我国家庭医生团队签约管理服务政策，提供了科学研究证据参考。