医疗联合体背景下脑心血管疾病共病的协同管理与实施路径研究

doi:10.3969/j.issn.1673-5765.2025.11.002

摘要/Abstract

摘要： 脑心血管疾病共病（以下简称脑心共病）的患病率持续上升，给我国乃至全球医疗体系造成沉重的疾病与经济负担。脑心共病的病理机制复杂，为满足患者的全周期健康服务需求，需构建协同管理的脑心同治模式。基于此，本文提出依托医疗联合体（以下简称医联体）制度优势，构建医联体内外协同的脑心同治模式。一方面，该模式强化医联体内部的分层联动与资源衔接，优化各级医疗机构的功能定位，完善双向转诊、信息互通及多学科协作机制；另一方面，该模式推动医联体与疾病预防控制中心、公共卫生机构及社会组织等外部主体协同合作，通过医防融合、社会参与和信息化平台建设，构建脑心共病的防控与健康支持网络。在实施路径方面，本文提出了计划-执行-研究-反馈（plan-do-study-act，PDSA）循环驱动的医联体脑心同治实践方案，规划了目标锚定、数据驱动、策略反馈与经验推广的流程。建议未来从政策顶层设计、基层网络构建、信息化平台建设、社会力量动员等多个维度系统推进，促进脑心共病从以治为主向医防融合、多元共治深入转型。本文旨在为提升脑心共病管理水平与医联体协同治理能力提供理论与实践参考。

文章导读： 本文立足于脑心共病的复杂病理机制，提出基于医联体的“内外协同”整合治理模式，旨在通过分层联动与资源衔接优化分级诊疗，基于PDSA循环质量改进模型，为构建全周期的健康服务体系提供参考。

关键词: 脑心血管疾病共病; 医疗联合体; 脑心同治

Abstract: The prevalence of comorbid cerebrocardiovascular diseases continues to rise, imposing a substantial disease and economic burden on healthcare systems in China and globally. The pathological mechanisms of comorbid cerebrocardiovascular diseases are complex. To meet the demand for full-cycle health services among patients, it is necessary to establish a collaborative management model for co-treatment of brain and heart. Based on this, this paper proposes leveraging the institutional advantages of the medical consortium to construct an internal-external coordination model for co-treatment of brain and heart. On the one hand, this model strengthens hierarchical coordination and resource integration within the medical consortium, optimizes the functional positioning of medical institutions at different levels, and improves mechanisms for two-way referral, information sharing, and multidisciplinary collaboration. On the other hand, it promotes collaborative cooperation between the medical consortium and external entities such as centers for disease control and prevention, public health institutions, and social organizations. Through the integration of medical treatment and prevention, social participation, and the development of information platforms, the model aims to establish a comprehensive network for prevention, control, and health support targeting comorbid cerebrocardiovascular diseases. In terms of implementation pathways, this paper puts forward a practical plan for co-treatment of brain and heart in medical consortium driven by the plan-do-study-act (PDSA) cycle, outlining processes including target anchoring, data-driven decision-making, strategy feedback, and experience promotion. It also suggests that future efforts should be systematically advanced from multiple dimensions, such as top-level policy design, grassroots network construction, information platform development, and social resources mobilization, to facilitate the transformation in addressing comorbid cerebrocardiovascular diseases from a “treatment-centered” to “integration of medical treatment and prevention” and “multi-stakeholder co-governance”. This paper aims to provide theoretical and practical references for improving the management level of comorbid cerebrocardiovascular diseases and enhancing the collaborative governance capacity of the medical consortium.

Key words: Comorbid cerebrocardiovascular disease; Medical consortium; Co-treatment of brain and heart

中图分类号:

罗志毅, 卞子豪, 孔凡懿, 杨燕绥, 申斗, 刘跃华. 医疗联合体背景下脑心血管疾病共病的协同管理与实施路径研究[J]. 中国卒中杂志, 2025, 20(11): 1345-1354.

LUO Zhiyi, BIAN Zihao, KONG Fanyi, YANG Yansui, SHEN Dou, LIU Yuehua. Study on Collaborative Management and Implementation Pathways for Comorbid Cerebrocardiovascular Diseases under the Framework of Medical Consortium[J]. Chinese Journal of Stroke, 2025, 20(11): 1345-1354.

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