Page 103 - 2022-25-中国全科医学

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9.Shanghai General Practice Clinical Quality Control Center，Shanghai 200090，China
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Corresponding author：ZHANG Hanzhi，Lecturer，Associate chief physician；E-mail：drchan001@163.com
【Abstract】 Background Osteoarthritis has a high rate of disability and deformity，and can be combined with several
physical and mental diseases. However，the early symptoms of the disease are not obvious. At present，there are problems in the
management of osteoarthritis in the community such as uncoordinated management，inadequate methods and imperfect systems.
Objective To construct and evaluate an informatics-based multidisciplinary management model for osteoarthritis patients in
community，to promote the management of community osteoarthritis patients and improve the prognosis of the patients. Methods
First a multidisciplinary management model of osteoarthritis patients in the community was constructed，including hierarchical
management process of patients based on risk factor stratification，the multidisciplinary management team and its division of
diagnosis and treatment，then an informatics based multidisciplinary management process was constructed，and information
software development was completed. From July 2019 to July 2020，80 patients with knee osteoarthritis who attended the general
outpatient clinics of Dinghai and Daqiao Community Health Service Centers in Shanghai，and the orthopedics outpatient clinics
of Yangpu District Central Hospital were randomly assigned into multidisciplinary management groups and general management
group，with 40 patients in each group. The patients in general group were given conventional treatment，while the patients in
multidisciplinary group were adopted information-based multidisciplinary management. Visual analogue scale（VAS）scores，
Western Ontario McMaster University（WOMAC） osteoarthritis index score，the simplified scale of Arthritis Quality Of Life
Measurement Scale（AIMS2） scores，Health Literacy Management Scale（HeLMS）scores，and body mass index（BMI）
were assessed before and after 12 weeks of management，respectively. Results Before treatment，there were no significant
differences in VAS score，WOMAC osteoarthritis index score，AIMS2 score，Helms score，and BMI between patients with knee
osteoarthritis in the multidisciplinary and general groups（P>0.05）. After 12 weeks of treatment，the VAS and WOMAC score of
both the multidisciplinary and general groups went down，and the health literacy AIMS2 scores and Helms total score were higher
after treatment than those before. The difference was statistically significant（P<0.05）. After 12 weeks of treatment，the AIMS2
total score and Helms total score of patients in the multidisciplinary group were higher than those in the general group，and the
VAS score，WOMAC osteoarthritis index，and BMI were lower than those in the general group， with significant differences（P<0.05）.
Conclusion The implementation of an informatics based community multidisciplinary management model for patients with
osteoarthritis of the knee can effectively reduce the patients' joint pain and control their weight，improve their ability of daily living
and health literacy，improve the quality of life of patients，and delay the progress of the disease.
【Key words】 Osteoarthritis；Community health services；Information technology；Disease management

骨关节炎在早期阶段通常没有明显症状，因此患 价（由于我国社区 >60 岁中老年人群膝骨关节炎患病
者感觉不适时通常已经发展到中后期，并且常会错过早 率较高 ［8］ ，故本研究选取膝骨关节炎患者为研究对象
期诊断和干预的机会。由于骨关节炎的致残和致畸率均 进行应用评价研究），以探索社区骨关节炎的优化管理
较高，长期的疾病治疗和管理会给患者和社会造成巨大 模式。
的经济负担。由于骨关节炎病程长且迁延不愈，患者的 1 基于信息化的社区骨关节炎患者多学科管理模式构建
生存质量较普通人群下降，甚至可能遭受精神问题，如 1.1 基于危险因素分层构建骨关节炎分级管理流程
注意力下降、紧张、焦虑、恐惧 ［1-2］ 。骨关节炎患者 参考骨关节炎诊疗指南（2018 年版） ［9］ ，根据患者的
参与数字化管理的实用性研究结果表明，电子医疗的个 疼痛评估〔视觉模拟评分法（VAS）评分、西安大略麦
性和便捷特性使其有潜力成为骨关节炎患者获取信息的 克马斯特大学（WOMAC）骨关节炎指数〕结果、治疗
首选来源，并可以充当早期疾病的管理工具；通过对骨 风险（胃肠道、心血管风险）及是否有合并疾病（肥胖、
关节炎患者进行信息化管理，可以减少其医疗资源的使 营养不良、糖尿病），具体将患者依据危险度分为低危、
用率 ［3］ 。基于对社区关节炎管理的文献查阅 ［4-7］ 及对 中危、高危、极高危（图 1）。然后依据危险度分层确
社区骨关节炎患者的认知和诊治行为特点调查分析，本 定患者干预措施的频率、强度和内容，危险度分层越高，
课题组发现当前社区骨关节炎管理方面存在的主要问题 干预措施的频率就越高，即针对不同分级给予不同需求
包括管理方法不健全、内容不具体、执行主体不明确、 的骨关节炎患者个性化的多学科（全科、康复、中医、
制度不完善等，主要管理策略包括对骨关节炎患者进行 营养、心理、骨科等）综合管理 ［10-11］ ，见表 1。
危险因素分层后实施多学科团队管理、充分利用远程电 1.2 确定多学科团队及其分工 由综合性医院和社区
子医疗服务进行管理。故本研究基于信息化系统构建社 卫生服务中心的全科医生、骨科医师、康复医师、中医
区骨关节炎全专结合的多学科管理模式，并进行应用评 医师、营养师、心理医师共同成立社区骨关节炎多学科