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

1.	國家衛生計生委疾病預防控制局. 中國居民營養與慢性病狀況報告(2015年)[R]. 北京: 人民衛生出版社, 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.	許迅, 鄒海東, 寧光. 從醫防融合的高度積極應對糖尿病視網膜病變的高發態勢[J]. 中華眼科雜志, 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.	張冰, 高靜歌, 潘成, 等. 成都市白內障和青光眼及年齡相關性黃斑變性知曉率及知識水平調查[J]. 國際眼科雜志, 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, 劉軍安, 等. 深圳市社區糖尿病患者視網膜病變防治知識知曉度及影響因素分析[J]. 中華眼底病雜志, 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.	馬福敏, 鐘偉強, 黃益民, 等. 上海市普陀區社區人群原發性高血壓患病率、知曉率、治療率和控制率的抽樣調查[J]. 中華高血壓雜志, 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.	戰義強, 余金明, 胡大一, 等. 北京居民糖尿病患病率及相關知識行為調查[J]. 中國公共衛生, 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, 蔣萍萍, 鄭廣勇, 等. 健康教育對社區高血壓患者生存質量的影響[J]. 中華老年心腦血管病雜志, 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, 王麗姿, 邵靜, 等. 動機性訪談干預對老年高血壓患者運動改變階段的影響[J]. 中華護理雜志, 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, 施秉銀, 等. 動機性訪談在糖尿病教育中的應用[J]. 中華護理雜志, 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.	孫曉紅, 劉珂珂, 江華, 等. 慢性病保健模型在糖尿病長期管理中的應用研究[J]. 中國全科醫學, 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.	劉薇薇, 王媛媛, 郝東惠, 等. 社區糖尿病患者自我管理狀況的影響因素研究[J]. 中國全科醫學, 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.	歐陽玲, 李寶琪, 楊輝. 瓦格納慢性病服務模型在中澳糖尿病管理中的運用[J]. 中國全科醫學, 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區常見慢性病疾病管理中的應用研究[D]. 杭州: 浙江大學, 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. 國家衛生計生委疾病預防控制局. 中國居民營養與慢性病狀況報告(2015年)[R]. 北京: 人民衛生出版社, 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. 許迅, 鄒海東, 寧光. 從醫防融合的高度積極應對糖尿病視網膜病變的高發態勢[J]. 中華眼科雜志, 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. 張冰, 高靜歌, 潘成, 等. 成都市白內障和青光眼及年齡相關性黃斑變性知曉率及知識水平調查[J]. 國際眼科雜志, 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, 劉軍安, 等. 深圳市社區糖尿病患者視網膜病變防治知識知曉度及影響因素分析[J]. 中華眼底病雜志, 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. 馬福敏, 鐘偉強, 黃益民, 等. 上海市普陀區社區人群原發性高血壓患病率、知曉率、治療率和控制率的抽樣調查[J]. 中華高血壓雜志, 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. 戰義強, 余金明, 胡大一, 等. 北京居民糖尿病患病率及相關知識行為調查[J]. 中國公共衛生, 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, 蔣萍萍, 鄭廣勇, 等. 健康教育對社區高血壓患者生存質量的影響[J]. 中華老年心腦血管病雜志, 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, 王麗姿, 邵靜, 等. 動機性訪談干預對老年高血壓患者運動改變階段的影響[J]. 中華護理雜志, 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, 施秉銀, 等. 動機性訪談在糖尿病教育中的應用[J]. 中華護理雜志, 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. 孫曉紅, 劉珂珂, 江華, 等. 慢性病保健模型在糖尿病長期管理中的應用研究[J]. 中國全科醫學, 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. 劉薇薇, 王媛媛, 郝東惠, 等. 社區糖尿病患者自我管理狀況的影響因素研究[J]. 中國全科醫學, 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. 歐陽玲, 李寶琪, 楊輝. 瓦格納慢性病服務模型在中澳糖尿病管理中的運用[J]. 中國全科醫學, 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區常見慢性病疾病管理中的應用研究[D]. 杭州: 浙江大學, 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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