中国成人动脉粥样硬化性心血管疾病基层管理路径专家共识(建议稿)  

Expert Consensus on the Clinical Pathways for the Atherosclerotic Cardiovascular Disease Management in Primary Care in Chinese Adults(Proposed Edition)

作　　者：曾益新[1] 祝墡珠[1] 于晓松[1] 王爽[1] 于凯[1] 祁慧萌[1] 

机构地区：[1]中华医学会全科医学分会慢病管理专业学组

出　　处：《中国全科医学》2017年第3期251-261,共11页Chinese General Practice

基　　金：国家自然科学基金资助项目(71273279)--基于全科医生连续性服务的整合式健康管理服务模式的研究;辽宁省科技计划项目(2013225089)--基于全科医生签约服务的代谢综合征临床管理整合模式研究;沈阳市科学技术计划项目(F13-220-9-62)--社区代谢综合征患者临床管理适宜技术规范化研究

摘　　要：为进一步规范全科医生及其团队心血管疾病基层管理的医疗服务行为,提高服务质量和医疗资源的利用效率,控制医疗风险和花费,使患者获得适宜、优质的基本医疗卫生服务,在中华医学会全科医学分会的建议和指导下,由该分会慢病管理专业学组组织多学科专家制定本专家共识(建议稿)。本共识(建议稿)按照《医疗机构临床路径的制定与实施》(WS/T393-2012)国家行业标准的基本要求,基于以人为中心、以循证为指导、规范化、标准化、持续改进以及以数据分析为依据的原则,为基层全科医生及其团队提供了科学规范的动脉粥样硬化性心血管疾病(ASCVD)基层管理路径,主要内容包括适用对象、诊断依据、转诊标准、ASCVD发病总体危险的评估、重点检查项目、制定基层管理计划的依据、基层管理计划、ASCVD主要危险因素基层管理目标、变异及其原因分析,并提供了具体的实施流程、路径表单和接诊流程。基层管理路径以多重心血管危险因素综合达标为核心,注重适用性和可行性,强调医患互动的有效性,规范了操作流程,有助于进一步促进以人为中心新型医疗服务模式的建立,提高基层管理质量和效率,推进家庭医生签约服务,助力分级诊疗制度建立和健康中国建设。This Expert Consensus on the Management Modes for Atherosclerotic Cardiovascular Disease in Chinese Adults in Primary Care（ Proposed Draft）〔hereinafter referred to as the Expert Consensus（ Proposed Draft）〕was developed by the Academic Group of Chronic Disease Management,The Society of General Practice,Chinese Medical Association,in order to further regulate the medical management of cardiovascular diseases of general practitioners（ GPs）and their team in primary care, to improve service quality and the utilization efficiency of medical resources,and to reduce the risk and cost of health care so that patients can get access to appropriate and high ―quality primary health care. In accordance with the basic requirements of the national profession standard of Development and implementation of clinical pathways for medical institutions（WS/T393―2012）, the Expert Consensus （ Proposed Draft ） provides scientific and standardized management pathways of atherosclerotic cardiovascular disease（ ASCVD）for GPs and their team in primary care,which is guided by the principles of person―centered care,evidence―based medicine,standardization and normalization,continuous improvement and data ―based analysis. The Expert Consensus（ Proposed Draft）mainly includes applicable subjects,diagnostic evidence,referral criteria,ASCVD risk assessment,major inspection items,scientific basis for the development of management plan for ASCVD,management plan for ASCVD,the control targets for the main risk factors of ASCVD,variation of management pathways and its causes along with the specific implementation flow chart, pathways form, and medical interview process. This Expert Consensus （ Proposed Draft ）＆nbsp;focuses on meeting the composite target objectives of multiple cardiovascular risk factors for ASCVD, pays attention to applicability and feasibility, emphasizes the effectiveness of doctor ― patient interaction, standardizes the management process. Important significance of the development of th

关 键 词：动脉粥样硬化 心血管疾病 危险因素 疾病管理 全科医学 专家共识 临床路径 

分 类 号：R54[医药卫生—心血管疾病]