CAJ | 학술논문

目的：了解我国慢性病管理实施现状，探索团队协作管理社区慢性病的改进方法。方法：利用关键词检索中国学术期刊网全文数据库、PubMed等常用中英文数据库，收集2008年1月至2013年12月公开发表的我国社区慢性病管理的研究报道，结合一定的纳入和排除标准，进行严格文献筛选；并基于慢性病团队协作管理模式对最后得出的文献进行归纳分析。结果：经系统检索后共得到698篇文献，进一步筛选得到33篇符合纳入标准的文献。在基于慢性病团队协作管理模式的几大要素中，全部文献涉及对慢性病患者的自我管理支持，但仅9篇提及团队成员之间的交流，11篇文献提及有明确的团队分工。结论：我国的社区慢性病管理工作存在不足，应建立一支真正意义上的全科服务团队，明确团队成员的角色与职责，提高团队成员的服务能力，同时应注意为患者提供多种形式的自我管理支持服务。
목적：료해아국만성병관리실시현상，탐색단대협작관리사구만성병적개진방법。방법：이용관건사검색중국학술기간망전문수거고、PubMed등상용중영문수거고，수집2008년1월지2013년12월공개발표적아국사구만성병관리적연구보도，결합일정적납입화배제표준，진행엄격문헌사선；병기우만성병단대협작관리모식대최후득출적문헌진행귀납분석。결과：경계통검색후공득도698편문헌，진일보사선득도33편부합납입표준적문헌。재기우만성병단대협작관리모식적궤대요소중，전부문헌섭급대만성병환자적자아관리지지，단부9편제급단대성원지간적교류，11편문헌제급유명학적단대분공。결론：아국적사구만성병관리공작존재불족，응건립일지진정의의상적전과복무단대，명학단대성원적각색여직책，제고단대성원적복무능력，동시응주의위환자제공다충형식적자아관리지지복무。
Objective: To evaluate the situation for chronic disease management in China, and to seek the method for improving the collaborative management for chronic diseases in community. Methods: We searched literature between January 2008 and November 2013 from the Database, such as China Academic Journal Full-Text Database, and PubMed. The screening was strictly in accordance with the inclusion and exclusion criteria and a summary was made among the selected literature based on a collaboration model. Results: We got 698 articles atfer rough screen and ifnally selected 33. All studies were involved in patient’s self-management support, but only 9 studies mentioned the communication within the team, and 11 showed a clear team division of labor. Conclusion: Chronic disease community management in China displays some disadvantages. It really needs a general service team with clear roles and responsibilities for team members to improve the service ability of team members and provide patients with various forms of self-management services.