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随着人们生活水平的提高与人口老龄化日益严重,我国疾病谱发生了显著的变化,慢性非传染病性疾病逐步取代传染病,成为影响人群健康的重要问题。慢性病因其发生发展受到生物、环境、心理等综合因素的影响,单纯的临床诊疗不足以控制人群慢性病的患病和进展。因此,以三级预防理论为基础的慢性病综合管理在实践中逐步得到发展。慢性病管理以社区为依托,社区慢性病管理是慢性病防治的关键环节。2012年是家庭医师制实施推进和深化内涵的
With the improvement of people’s living standards and the aging population, the disease spectrum in our country has undergone significant changes. The chronic non-communicable diseases gradually replace infectious diseases and become an important issue affecting the health of the population. The development of chronic diseases due to biological, environmental, psychological and other comprehensive factors, simple clinical diagnosis and treatment is not enough to control the population of chronic diseases and progression. Therefore, the integrated management of chronic diseases based on tertiary prevention theory has been gradually developed in practice. Chronic disease management Community-based, community chronic disease management is the key link in the prevention and control of chronic diseases. 2012 is the implementation of family physicians to promote and deepen the connotation