骨质疏松是一种以骨量减少、骨组织微结构破坏、骨脆性增加及易于骨折为特征的代谢性骨病.家庭医生签约服务是指由一名家庭医生对区域内人口进行健康管理,使得医疗资源得到最大限度的优化、最合理的分配和利用.在家庭医生签约服务的背景下,如何建立骨质疏松的健康管理路径,并使其与区域签约制度联合是目前社区专病防治路径建设的难点之一.本研究通过文献研究的方法,汇总并分析了当前国内外与骨质疏松防治相关的指南,并以其为基础,采用专家咨询法、头脑风暴法、流程图法构建骨质疏松专病防治路径,最终在三林社区家庭医生签约服务云平台APP中添加了骨质疏松专病防治模块.该模块可以满足社区骨质疏松的筛查、诊断、治疗、康复及信息化管理,已经进入可实施、可应用阶段,应用前景良好.%Osteoporosis is a metabolic bone disease characterized by decrease in bone mass,damage in bone tissue microstructure,increased bone fragility and susceptibility to fracture. The family doctor's contract service is a kind of health management delivered by a family doctor for the people in the area for which the family doctor is responsible,and during the service delivery,the medical resources are optimized at utmost,and allocated and used most reasonably. Currently,one of the difficulties in constructing the path of community specific disease prevention and treatment is,building an osteoporosis health management path that is well associated with the regional contract service system,by which the contracted family doctor can better offer the services. The ways that we used to solve this problem are as follows:Firstly,we investigated the guidelines related to osteoporosis prevention and treatment at home and abroad included by literature search,and chose tools for screening,diagnosis, treatment and follow - up strategies of osteoporosis. Then,in accordance with the experts' review on the literature retrieval results, we selected the appropriate screening,diagnosis and treatment tools for osteoporosis. Next,we set the related structured themes by brainstorming,in which we identified the procedure of using the tools and obtained the logical chart of community osteoporosis prevention and treatment path. And on the basis of the above,we constructed the flow chart of community osteoporosis prevention and treatment path. Finally,we developed the community osteoporosis prevention and treatment module based on all the above, and added it to Sanlin family doctor service cloud APP platform. This module was taken into practice. It can meet the needs of screening,diagnosis,treatment,rehabilitation,and informationalized management of osteoporosis with a good application prospect.
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