南通市医防协同管理模式下脑卒中现状及四级预防

doi:10.3969/j.issn.1006-7795.2025.01.010

首都医科大学学报 ›› 2025, Vol. 46 ›› Issue (1): 63-67.doi: 10.3969/j.issn.1006-7795.2025.01.010

• 国家卫生健康委加强脑卒中防治工作减少百万新发残疾工程 • 上一篇下一篇

南通市医防协同管理模式下脑卒中现状及四级预防

刘肖朦^1，2，3，周绍娟¹，邵小红^1，3，徐文平⁶，宦峰^3，5，朱向阳^3，4*

1.南通市疾病预防控制中心医防管理科，江苏南通 226000；2.南通大学公共卫生应用研究院，江苏南通 226000；3.南通市心脑血管病医防协同中心，江苏南通 226000；4.南通市第一人民医院神经内科，江苏南通 226000；5.南通市第一人民医院公共卫生与医防协同处，江苏南通 226000；6.江苏省南通卫生高等职业技术学校检验系，江苏南通 226000

收稿日期:2024-11-06 出版日期:2025-02-21 发布日期:2025-02-24
通讯作者: 朱向阳 E-mail:zhuxxyy@163.com
基金资助:
江苏省卫生健康委员会科研课题（Y12023023）,江苏省职业健康科研项目（JSZJ20241103）,南通市科技局项目（MS22022121）,南通市卫生健康委员会科研项目（MS2023088）,南通市卫生健康委员会科技项目（MS2024029）。

Current situation and four-level prevention of stroke under the collaborative management model between medical prevention and treatment in Nantong

Liu Xiaomeng^1，2，3，Zhou Shaojuan¹，Shao Xiaohong^1，3，Xu Wenping⁶，Huan Feng^3，5，Zhu Xiangyang^3，4*

1.Medical Prevention Management Section,Nantong Center for Disease Control and Prevention,Nantong 226000, Jiangsu Province, China; 2.Institute of Public Health Application of Nantong University,Nantong 226000, Jiangsu Province, China; 3.Nantong Medical and Prevention Collaborative Center for Cardiovascular and Cerebrovascular Disease,Nantong 226000, Jiangsu Province, China; 4.Department of Neurology,Nantong First People's Hospital, Nantong 226000, Jiangsu Province, China; 5.Department of Public Health and Medical Prevention,Nantong First People's Hospital, Nantong 226000, Jiangsu Province, China; 6.Department of Inspection,Nantong Health College of Jiangsu Province,Nantong 226000, Jiangsu Province, China

Received:2024-11-06 Online:2025-02-21 Published:2025-02-24
Supported by:
This study was supported by the Research Project of Jiangsu Provincial Health Commission (Y12023023), Jiangsu Province Occupational Health Research Project (JSZJ20241103),Nantong Science and Technology Bureau Project (MS22022121),the Research Project of Nantong Health Commission (MS2023088),the Research Project of Nantong Health Commission (MS2024029).

摘要/Abstract

摘要： 目的分析南通市心脑血管病医防协同中心脑卒中四级预防创新模式及其成效，为脑血管病的防治提供新的实践经验。方法南通市在实践中探索出心脑血管病医防协同的“53343”模式，创新性将该模式融入到四级预防中，形成零级引导、一级监测、二级协同、三级主导的脑卒中防治实践模式。收集《中国卫生健康统计年鉴》2011—2022年数据以及江苏省慢性病管理信息平台2017—2023年南通市心脑血管事件监测数据，用Excel和SPSS 24.0处理数据，分析应用医防协同模式后，南通市脑卒中监测数据变化情况及成效。结果在连续5年监测人数递增的情况下，南通市心脑血管病医防协同中心脑卒中监测数据2022年首次出现了监测人数回落；2017至2021年,南通市心脑血管病医防协同中心的脑卒中监测数据与全国脑卒中患者出院人数相比波动趋势更平稳。建立了连贯的健康服务运行机制，培养了14名复合型人才，成功举办脑卒中专题继续教育培训班，加强了临床与公卫的深入协同，为有效防治脑卒中提供了实践创新模式。结论基于心脑血管病医防协同中心的四级预防模式能够实现全流程全周期健康管理，可有效减缓脑卒中的上升趋势，提升科教研能力和水平。

关键词: 医防协同, 脑卒中, 四级预防

Abstract: Objective To analyze the innovative model and effectiveness of the four-level prevention of stroke in Nantong Medical and Prevention Collaborative Center for Cardiovascular and Cerebrovascular Disease,so as to provide new practical experience for the prevention and treatment of cerebrovascular disease. Methods In practice, Nantong city has explored the “53343” mode of collaborative treatment and prevention of cardiovascular and cerebrovascular diseases, and innovatively integrated this mode into four-level prevention to form a practice mode of zero-level guidance, first-level monitoring, second-level coordination and three-level leading. Data from the China Health Statistics Yearbook from 2011 to 2022 and the monitoring data of cardiovascular and cerebrovascular events in Nantong City on the Jiangsu Provincial Chronic Disease Management Information Platform from 2017 to 2023 were collected and processed by using Excel and SPSS 24.0, to analyze the changes of stroke surveillance data and effectiveness in Nantong City after applying the model. Results According to the monitoring data of cardiovascular and cerebrovascular events in Nantong City from the Jiangsu Provincial Chronic Disease Management Information Platform, despite the continuous increase in the number of monitored individuals over five years, the monitoring data for stroke from the Nantong Medical and Prevention Collaborative Center for Cardiovascular and Cerebrovascular Disease witnessed a decline in the number of monitored individuals for the first time in 2022. The stroke monitoring data from the same monitoring agency showed a more stable fluctuation trend compared to the number of national stroke patients discharged from 2017 to 2021. We established a coherent health service operation mechanism, cultivated 14 interdisciplinary talents, held a special continuing education class on stroke, strengthened the in-depth collaboration between clinical and public health, and provided a practical and innovative model for effective prevention and treatment of stroke. Conclusions The four-level prevention based on the medical and preventive collaboration center for cardiovascular and cerebrovascular diseases can achieve process and cycle health management, effectively slow down the upward trend of stroke, and improve the ability and level of scientific research and teaching.

Key words: collaboration between medical and preventive, stroke, fourth-level prevention

中图分类号:

R743.3

刘肖朦, 周绍娟, 邵小红, 徐文平, 宦峰, 朱向阳. 南通市医防协同管理模式下脑卒中现状及四级预防[J]. 首都医科大学学报, 2025, 46(1): 63-67.

Liu Xiaomeng, Zhou Shaojuan, Shao Xiaohong, Xu Wenping, Huan Feng, Zhu Xiangyang. Current situation and four-level prevention of stroke under the collaborative management model between medical prevention and treatment in Nantong[J]. Journal of Capital Medical University, 2025, 46(1): 63-67.

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南通市医防协同管理模式下脑卒中现状及四级预防

Current situation and four-level prevention of stroke under the collaborative management model between medical prevention and treatment in Nantong

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