Scott I A
Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.
Intern Med J. 2008 Jun;38(6):427-37. doi: 10.1111/j.1445-5994.2007.01524.x. Epub 2008 Feb 20.
Approximately one in three Australians or 6.8 million individuals suffer from one or more chronic diseases, the most prevalent being ischaemic heart disease, congestive heart failure, chronic obstructive lung disease, diabetes and renal disease. Potentially avoidable hospitalizations related to chronic disease comprise 5.5% of all admissions nationally and cluster in older age groups and socioeconomically disadvantaged regions. In an effort to reduce mortality and morbidity, programmes of chronic disease management have evolved with the aim of achieving formalized, population-wide implementation of elements of the chronic care model developed by Wagner et al. Results of rigorous evaluations of such programmes suggest improved survival and/or disease control with reductions in hospitalizations and adverse clinical events. This paper aims to provide an overview of available evidence for chronic disease management programmes for practising physicians who will be increasingly invited to take an active leadership role in designing and operationalizing such programmes.
大约三分之一的澳大利亚人，即680万人，患有一种或多种慢性病，其中最常见的是缺血性心脏病、充血性心力衰竭、慢性阻塞性肺病、糖尿病和肾病。与慢性病相关的潜在可避免住院占全国所有住院病例的5.5%，且集中在老年人群体和社会经济地位不利的地区。为了降低死亡率和发病率，慢性病管理项目不断发展，旨在实现由瓦格纳等人开发的慢性病护理模式要素在全人群中的正式实施。对此类项目的严格评估结果表明，生存率提高和/或疾病得到控制，住院率和不良临床事件减少。本文旨在为执业医生提供有关慢性病管理项目的现有证据概述，这些医生将越来越多地被邀请在设计和实施此类项目中发挥积极的领导作用。
