Chronic disease management approaches for fundus disease to be explored and established_Chinese Journal of Ocular Fundus Diseases

Authors：

Li Shu ^1,2,3 , Xu Yan ^1,2 , Fang Fang ^1,2,3 , Fang Qiong ³ , Liu Kun ^1,2 ,  Xu Xun ^1,2

1. Department of Ophthalmology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China;
2. National Clinical Research Center for Eye Diseases, Shanghai General Hospital, Shanghai 200080, China;
3. Shanghai Jiao Tong University School of Nursing, Shanghai 200240, China;

Corresponding author：

Xu Xun, Email: drxuxun@sjtu.edu.cn

Keywords：

Fundus disease; Chronic disease management; Review

DOI：

10.3760/cma.j.cn511434-20211021-00594

Video：

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Chronic disease is a major threat to human health. Fundus disease has become a major ophthalmic disease affecting daily life. Although great breakthroughs have been made in the treatment, compared with other chronic disease management, the management of patients with fundus disease is still in its infancy. To strengthen the management exploration of patients with fundus diseases, establish a management model of fundus diseases and strive to improve patients' awareness of fundus diseases and adherence to treatment and follow-up are the great challenges at present. All ophthalmic centers should strengthen patient education, establish a regional cooperation network, support the construction of grassroots medical capacity, cultivate talents, enhance training, promote the standardized treatment of fundus diseases, standardize fundus imaging inspection and diagnosis, and promote the homogeneous construction of diagnosis and treatment of chronic fundus diseases. We will accelerate the construction of a hierarchical diagnosis and treatment system and the ability to link consultation and referral. Through systematic management and intervention of fundus diseases, a large number of patients with fundus diseases will receive early screening, diagnosis, standardized continuous treatment and systematic management, and improve the quality of life of patients with fundus diseases.

Citation： Li Shu, Xu Yan, Fang Fang, Fang Qiong, Liu Kun, Xu Xun. Chronic disease management approaches for fundus disease to be explored and established. Chinese Journal of Ocular Fundus Diseases, 2023, 39(2): 181-183. doi: 10.3760/cma.j.cn511434-20211021-00594 Copy

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9.	薛金玉, 蒋萍萍, 郑广勇, 等. 健康教育对社区高血压患者生存质量的影响[J]. 中华老年心脑血管病杂志, 2015, 17(10): 1048-1051. DOI: 10.3969/j.issn.1009-0126.2015.10.011.Xue JY, Jiang PP, Zheng GY, et al. Influence of health education on quality of life in community hypertensive patients[J]. Chin J Geriatr Heart Brain Vessel Dis, 2015, 17(10): 1048-1051. DOI: 10.3969/j.issn.1009-0126.2015.10.011.
10.	曹雪群, 王丽姿, 邵静, 等. 动机性访谈干预对老年高血压患者运动改变阶段的影响[J]. 中华护理杂志, 2012, 47(1): 20-22. DOI: 10.3761/j.issn.0254-1769.2012.01.007.Cao XQ, Wang LZ, Shao J, et al. Impact of motivational interviewing on the behavior change stages in elderly patients with hypertension[J]. Chin J Nurs, 2012, 47(1): 20-22. DOI: 10.3761/j.issn.0254-1769.2012.01.007.
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12.	孙晓红, 刘珂珂, 江华, 等. 慢性病保健模型在糖尿病长期管理中的应用研究[J]. 中国全科医学, 2018, 21(31): 3878-3881. DOI: 10.12114/j.issn.1007-9572.2018.00.043.Sun XH, Liu KK, Jiang H, et al. Chronic care model in long-term management of diabetes[J]. Chinese General Practice, 2018, 21(31): 3878-3881. DOI: 10.12114/j.issn.1007-9572.2018.00.043.
13.	刘薇薇, 王媛媛, 郝东惠, 等. 社区糖尿病患者自我管理状况的影响因素研究[J]. 中国全科医学, 2013, 16(21): 1862-1864. DOI: 10.3969/j.issn.1007-9572.2013.06.014.Liu WW, Wang YY, Hao DH, et al. Factors impacting self-management among diabetes patients in communities[J]. Chinese General Practice, 2013, 16(21): 1862-1864. DOI: 10.3969/j.issn.1007-9572.2013.06.014.
14.	欧阳玲, 李宝琪, 杨辉. 瓦格纳慢性病服务模型在中澳糖尿病管理中的运用[J]. 中国全科医学, 2020, 23(33): 4236-4240. DOI: 10.12114/j.issn.1007-9572.2020.00.443.Ouyang L, Li BQ, Yang H. Applying the Wagner chronic care model in diabetes management: Australian experience and implications to China[J]. Chinese General Practice, 2020, 23(33): 4236-4240. DOI: 10.12114/j.issn.1007-9572.2020.00.443.
15.	Kong JX, Zhu L, Wang HM, et al. Effectiveness of the chronic care model in type 2 diabetes management in a Community Health Service Center in China: A Group Randomized Experimental Study[J/OL]. J Diabetes Res, 2019: 6516581[2019-01-03]. https://pubmed.ncbi.nlm.nih.gov/30719455/. DOI: 10.1155/2019/6516581.
16.	郭岸英. 慢性病保健模型在社区常见慢性病疾病管理中的应用研究[D]. 杭州: 浙江大学, 2011.Guo AY. Application of chronic care model in community chronic disease management[D]. Hangzhou: Zhejiang University, 2011.
17.	Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, et al. Effects of intensive glucose lowering in type 2 diabetes[J]. N Engl J Med, 2008, 358(24): 2545-2559. DOI: 10.1056/NEJMoa0802743.
18.	Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes[J]. N Engl J Med, 2008, 359(15): 1577-1589. DOI: 10.1056/NEJMoa0806470.
19.	ACCORD Study Group, ACCORD Eye Study Group, Chew EY, et al. Effects of medical therapies on retinopathy progression in type 2 diabetes[J]. N Engl J Med, 2010, 363(3): 233-244. DOI: 10.1056/NEJMoa1001288.
20.	Jin P, Peng J, Zou H, et al. A five-year prospective study of diabetic retinopathy progression in Chinese type 2 diabetes patients with "well-controlled" blood glucose[J/OL]. PLoS One, 2015, 10(4): e0123449[2015-04-07]. https://pubmed.ncbi.nlm.nih.gov/25849536/. DOI: 10.1371/journal.pone.0123449.

1. 国家卫生计生委疾病预防控制局. 中国居民营养与慢性病状况报告(2015年)[R]. 北京: 人民卫生出版社, 2016.State Health and Family Planning Commission Disease Control and Prevention Bureau. Report on nutrition and chronic diseases in China (2015)[R]. Beijing: People's Medical Publishing House, 2016.
2. 许迅, 邹海东, 宁光. 从医防融合的高度积极应对糖尿病视网膜病变的高发态势[J]. 中华眼科杂志, 2015, 51(11): 801-803. DOI: 10.3760/cma.j.issn.0412-4081.2015.11.001.Xu X, Zou HD, Ning G. Active response to high momentum of diabetic retinopathy with the strategy of combined treatment and prevention[J]. Chin J Ophthalmol, 2015, 51(11): 801-803. DOI: 10.3760/cma.j.issn.0412-4081.2015.11.001.
3. 张冰, 高静歌, 潘成, 等. 成都市白内障和青光眼及年龄相关性黄斑变性知晓率及知识水平调查[J]. 国际眼科杂志, 2016, 16(3): 397-402. DOI: 10.3980/j.issn.1672-5123.2016.3.01.Zhang B, Gao JG, Pan C, et al. Awareness and knowledge about cataract, glaucoma, and age-related macular degeneration in Chengdu, China[J]. Int Eye Sci, 2016, 16(3): 397-402. DOI: 10.3980/j.issn.1672-5123.2016.3.01.
4. 彭云, 郭千千, 刘军安, 等. 深圳市社区糖尿病患者视网膜病变防治知识知晓度及影响因素分析[J]. 中华眼底病杂志, 2021, 37(1): 21-26. DOI: 10.3760/cma.j.cn511434-20201119-00570.Peng Y, Guo QQ, Liu JA, et al. A survey of awareness of retinopathy among diabetic patients in communities of Shenzhen[J]. Chin J Ocul Fundus Dis, 2021, 37(1): 21-26. DOI: 10.3760/cma.j.cn511434-20201119-00570.
5. 马福敏, 钟伟强, 黄益民, 等. 上海市普陀区社区人群原发性高血压患病率、知晓率、治疗率和控制率的抽样调查[J]. 中华高血压杂志, 2010, 18(11): 1059-1062. DOI: 10.16439/j.cnki.1673-7245.2010.11.018.Ma FM, Zhong WQ, Huang YM, et al. Sampling survey of prevalence, awareness, treatment, and control rate of hypertension in Community in Putuo District, Shanghai[J]. Chin J Hypertens, 2010, 18(11): 1059-1062. DOI: 10.16439/j.cnki.1673-7245.2010.11.018.
6. 战义强, 余金明, 胡大一, 等. 北京居民糖尿病患病率及相关知识行为调查[J]. 中国公共卫生, 2012, 28(1): 19-21. DOI: 10.11847/zgggws2012-28-01-08.Zhan YQ, Yu JM, Hu DY, et al. Prevalence and related knowledge of diabetes mellitus among residents of Beijing[J]. Chin J Public Health, 2012, 28(1): 19-21. DOI: 10.11847/zgggws2012-28-01-08.
7. Wagner EH. Organizing care for patients with chronic illness revised[J]. Milbank Q, 2019, 97(3): 659-664. DOI: 10.1111/1468-0009.12416.
8. Luepker RV, Murray DM, Jacobs DR Jr, et al. Community education for cardiovascular disease prevention: risk factor changes in the Minnesota Heart Health Program[J]. Am J Public Health, 1994, 84(9): 1383-1393. DOI: 10.2105/ajph.84.9.1383.
9. 薛金玉, 蒋萍萍, 郑广勇, 等. 健康教育对社区高血压患者生存质量的影响[J]. 中华老年心脑血管病杂志, 2015, 17(10): 1048-1051. DOI: 10.3969/j.issn.1009-0126.2015.10.011.Xue JY, Jiang PP, Zheng GY, et al. Influence of health education on quality of life in community hypertensive patients[J]. Chin J Geriatr Heart Brain Vessel Dis, 2015, 17(10): 1048-1051. DOI: 10.3969/j.issn.1009-0126.2015.10.011.
10. 曹雪群, 王丽姿, 邵静, 等. 动机性访谈干预对老年高血压患者运动改变阶段的影响[J]. 中华护理杂志, 2012, 47(1): 20-22. DOI: 10.3761/j.issn.0254-1769.2012.01.007.Cao XQ, Wang LZ, Shao J, et al. Impact of motivational interviewing on the behavior change stages in elderly patients with hypertension[J]. Chin J Nurs, 2012, 47(1): 20-22. DOI: 10.3761/j.issn.0254-1769.2012.01.007.
11. 李蒙, 李婷, 施秉银, 等. 动机性访谈在糖尿病教育中的应用[J]. 中华护理杂志, 2012, 47(2): 187-189. DOI: 10.3761/j.issn.0254-1769.2012.02.037.Li M, Li T, Shi BY, et al. Motivational interviewing in patient education of diabetes mellitus[J]. Chin J Nurs, 2012, 47(2): 187-189. DOI: 10.3761/j.issn.0254-1769.2012.02.037.
12. 孙晓红, 刘珂珂, 江华, 等. 慢性病保健模型在糖尿病长期管理中的应用研究[J]. 中国全科医学, 2018, 21(31): 3878-3881. DOI: 10.12114/j.issn.1007-9572.2018.00.043.Sun XH, Liu KK, Jiang H, et al. Chronic care model in long-term management of diabetes[J]. Chinese General Practice, 2018, 21(31): 3878-3881. DOI: 10.12114/j.issn.1007-9572.2018.00.043.
13. 刘薇薇, 王媛媛, 郝东惠, 等. 社区糖尿病患者自我管理状况的影响因素研究[J]. 中国全科医学, 2013, 16(21): 1862-1864. DOI: 10.3969/j.issn.1007-9572.2013.06.014.Liu WW, Wang YY, Hao DH, et al. Factors impacting self-management among diabetes patients in communities[J]. Chinese General Practice, 2013, 16(21): 1862-1864. DOI: 10.3969/j.issn.1007-9572.2013.06.014.
14. 欧阳玲, 李宝琪, 杨辉. 瓦格纳慢性病服务模型在中澳糖尿病管理中的运用[J]. 中国全科医学, 2020, 23(33): 4236-4240. DOI: 10.12114/j.issn.1007-9572.2020.00.443.Ouyang L, Li BQ, Yang H. Applying the Wagner chronic care model in diabetes management: Australian experience and implications to China[J]. Chinese General Practice, 2020, 23(33): 4236-4240. DOI: 10.12114/j.issn.1007-9572.2020.00.443.
15. Kong JX, Zhu L, Wang HM, et al. Effectiveness of the chronic care model in type 2 diabetes management in a Community Health Service Center in China: A Group Randomized Experimental Study[J/OL]. J Diabetes Res, 2019: 6516581[2019-01-03]. https://pubmed.ncbi.nlm.nih.gov/30719455/. DOI: 10.1155/2019/6516581.
16. 郭岸英. 慢性病保健模型在社区常见慢性病疾病管理中的应用研究[D]. 杭州: 浙江大学, 2011.Guo AY. Application of chronic care model in community chronic disease management[D]. Hangzhou: Zhejiang University, 2011.
17. Action to Control Cardiovascular Risk in Diabetes Study Group, Gerstein HC, Miller ME, et al. Effects of intensive glucose lowering in type 2 diabetes[J]. N Engl J Med, 2008, 358(24): 2545-2559. DOI: 10.1056/NEJMoa0802743.
18. Holman RR, Paul SK, Bethel MA, et al. 10-year follow-up of intensive glucose control in type 2 diabetes[J]. N Engl J Med, 2008, 359(15): 1577-1589. DOI: 10.1056/NEJMoa0806470.
19. ACCORD Study Group, ACCORD Eye Study Group, Chew EY, et al. Effects of medical therapies on retinopathy progression in type 2 diabetes[J]. N Engl J Med, 2010, 363(3): 233-244. DOI: 10.1056/NEJMoa1001288.
20. Jin P, Peng J, Zou H, et al. A five-year prospective study of diabetic retinopathy progression in Chinese type 2 diabetes patients with "well-controlled" blood glucose[J/OL]. PLoS One, 2015, 10(4): e0123449[2015-04-07]. https://pubmed.ncbi.nlm.nih.gov/25849536/. DOI: 10.1371/journal.pone.0123449.

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Chronic disease management approaches for fundus disease to be explored and established

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