基于癌症生存照护理论的社区肿瘤随访服务内容框架构建研究
Study on Constructing Content Framework for Follow-up of Cancer in Primary Care Based on Cancer Survivorship Care Quality Framework
王佳敏 1孙可欣 2张雨晴 3孙晓杰3
作者信息
- 1. 250021 山东济南山东第一医科大学附属省立医院（山东省立医院）组织人事部（人才工作办公室）
- 2. 100021 北京国家癌症中心国家肿瘤临床医学研究中心中国医学科学院北京协和医学院肿瘤医院肿瘤登记办公室
- 3. 250012 山东济南山东大学卫生管理与政策研究中心（山东省重点新型智库）;250012 山东济南国家卫生健康委员会卫生经济与政策研究重点实验室（山东大学）;250012 山东济南山东大学齐鲁医学院公共卫生学院社会医学与卫生事业管理学系
- 折叠
摘要
背景 我国已建立覆盖全国的肿瘤登记体系，为社区肿瘤随访服务提供了数据基础，但现有医疗资源分配不平衡且服务效率低下，难以满足癌症慢病化管理需求，因此有必要聚焦重点服务内容，探索建立持之有效的可复制的社区肿瘤随访服务模式，以提升癌症生存照护质量。目的 本研究旨在构建适用于我国国情的社区肿瘤随访服务内容框架，识别核心服务内容，为完善我国现有的肿瘤随访管理模式提供依据。方法 首先，以癌症生存照护质量框架为理论基础，初步构建社区肿瘤随访服务内容框架。其次，通过检索PubMed和Web of Science等英文数据库，以及中国知网、万方数据知识服务平台等中文数据库，同时结合Google学术搜索引擎，检索时间限定为2000—2023年，系统回顾与社区肿瘤随访服务相关的文献和政策文本，聚焦并提炼出社区肿瘤随访服务的核心内容。最后，于2023年12月—2024年02月通过电子邮件向专家发送咨询问卷，在判断专家积极程度、专家权威程度和专家协调程度的基础上完成2轮德尔菲专家咨询，通过定性与定量分析对条目进行了调整和修改，确定社区肿瘤随访服务内容框架。结果 共18位专家参与2轮咨询，专家对2轮问卷的回复率和有效率均为100%，积极性较高；权威系数均>0.7，权威性较好；协调系数的P均含健康监测、医疗干预、健康促进和健康评估4项主类别条目；风险因素监测、日常体检复查、风险规避干预、推荐疗法使用、健康知识科普、健康经验交流、肿瘤预后评估和慢病共病评估8项次类别条目以及24项子类别条目的社区肿瘤随访服务内容框架。结论 建议以本内容框架为指导，重点加强全科医生团队在肿瘤慢病管理和康复指导等方面的能力培训；积极扩展社区肿瘤随访服务内容，提高肿瘤随访服务的吸引力，以全方位支持患者的身心恢复。
Abstract
BackgroundChina has established a nationwide cancer registry system that provides a solid data foundation for cancer follow-up services in primary care. However, the imbalance in medical resource allocation and the low efficiency of existing services hinder the chronic disease management of cancer. Therefore, it is essential to identify key service components and develop an effective, replicable cancer follow-up service model in primary care to enhance the quality of cancer survivorship care. ObjectiveThis study aimed to construct a content framework for follow-up of cancer in primary care which was suitable for Chinas national context, identify core service components, and provide evidence for improving the current cancer follow-up management model in China. MethodsFirst, based on the Cancer Survivorship Care Quality Framework, a preliminary content framework for follow-up of cancer in primary care was developed. Second, a systematic review of literature and policy documents related to follow-up of cancer in primary care was conducted by searching English databases including PubMed and Web of Science, Chinese databases including CNKI and Wanfang Data, as well as the Google Scholar search engine. The search period was limited from 2000 to 2023. Core components of follow-up of cancer in primary care were identified and refined. Finally, from December 2023 to February 2024, expert consultation questionnaires were distributed by email. Based on assessments of expert enthusiasm, authority, and coordination, two rounds of Delphi expert consultation were completed. Through qualitative and quantitative analyses, the items were revised and refined, resulting in a final framework. ResultsA total of 18 experts participated two consultation rounds. The response and validity rates of the questionnaires were both 100%, indicating high enthusiasm; the authority coefficient exceeded 0.7, reflecting good authority; and the coordination coefficient P-values were all <0.001, suggesting strong consistency among expert ratings. After two rounds of scoring and selection, the final framework comprised four primary categories-health monitoring, medical intervention, health promotion, and health assessment; eight secondary categories-risk factor monitoring, routine examination review, risk avoidance intervention, recommended therapy utilization, health knowledge dissemination, health experience exchange, cancer prognosis evaluation, and comorbidity assessment; as well as 24 specific subcategories. ConclusionIt is recommended that this framework be adopted to guide practice, with emphasis on strengthening general practitionerscapacity in chronic cancer management and rehabilitation guidance; actively expanding the scope of followup of cancer in primary care; and enhancing the attractiveness of such services, thereby providing comprehensive support for patients physical and psychological recovery.关键词
癌症/肿瘤随访/社区/肿瘤登记系统/山东省/德尔菲专家咨询法引用本文复制引用
王佳敏,孙可欣,张雨晴,孙晓杰.基于癌症生存照护理论的社区肿瘤随访服务内容框架构建研究[EB/OL].(2026-05-13)[2026-06-10].https://chinaxiv.org/abs/202605.00092.学科分类
肿瘤学
