研究目的：

总结提取影响慢性病健康管理服务的影响因素，构建慢性病健康管理服务影响因素的分析框架，并以浙江省长兴县为案例，对其慢性病健康管理措施进行系统分析，为进一步完善我国慢性病健康管理工作提供参考借鉴。

研究方法：

1.运用文献研究法检索、筛选研究健康管理服务影响因素相关文献，运用扎根理论提取形成慢性病健康管理服务影响因素集、构建影响因素分析框架。

2.对15位卫生政策相关领域的专家开展专家咨询，完善各影响因素概念规范及层级关系，最终形成本研究的慢性病健康管理服务影响因素分析框架。

3.分析浙江省长兴县这一典型案例，一是根据上述影响因素分析框架，从官方政策文件、相关文献、权威新闻报道等来源收集资料，系统梳理长兴县慢性病健康管理服务的具体政策措施；二是通过目的抽样法，对16名浙江省长兴县慢性病健康管理服务相关政策制定者、医务人员、患者进行半结构化的个人深度访谈，了解长兴县针对前文影响因素框架中的各影响因素分别采取了哪些措施，进一步探索各影响因素的实际作用和影响机制。

研究结果：

本研究提炼了慢性病健康管理服务影响因素，构建了慢性病健康管理服务影响因素分析框架，具体包括了3大类别（需求因素、供给因素和治理因素），9个主范畴（基层卫生人员、服务提供方式、基础设施等），18个影响因素（覆盖范围、人员数量、信息化建设、监督考核、协作整合等）。该框架经过专家咨询法进行评价和修改，专家意见主要集中在删除重复或补充遗漏的条目、规范化语言表达、合并或拆分模糊的条目三方面。

长兴县在开展免费体检筛查、组团式提供网格化的健康管理、信息化平台建设、常态化的基层卫生人员培养等方面采取了一系列有效的措施，提高了慢性病健康管理服务的质量和效率，实现了“两慢病”的全流程闭环管理。但在常态化专项经费保障、完善监督考核和绩效激励机制上仍存在一定挑战。

研究结论：

本研究认为，提供优质高效的慢性病健康管理服务应该针对需求因素、供给因素和治理因素三个层面的影响因素进行综合考量和重点推进，其中需求因素决定了居民和患者对服务的认知和利用，供给因素的人员、设施和服务方式直接影响了服务的内容、质量和效果，治理因素的政府重视程度、资金保障和监督激励机制影响了服务的实际效果和效率。建议针对薄弱环节和重点人群，采取需求导向的针对性干预措施；加强数字信息化建设，形成健康管理闭环；加强现有资源的协作整合，发挥医共体优势，组团式提供网格化健康管理服务；完善经费保障机制和考核激励机制等。本研究为提高慢性病健康管理服务质量、效果和效率提供了理论依据和经验参考。

Objective:

To summarize and extract the influencing factors of chronic disease health management services, construct an analytical framework of influencing factors of chronic disease health management services, and take Changxing County in Zhejiang Province as a case study to systematically analyze its chronic disease health management measures, in order to provide reference for further improving chronic disease health management work in China.

Methods:

1. Using literature research method to retrieve and screen relevant literature on influencing factors of health management services, and using grounded theory to extract and form a set of influencing factors of chronic disease health management services.

2. From the three aspects of demand factors, supply factors and governance factors, an analytical framework of influencing factors of chronic disease health management services is constructed. And 15 experts in the field of health policy were consulted to improve the conceptual norms and hierarchical relationships of each influencing factor, and finally formed the analytical framework of influencing factors of chronic disease health management services in this study.

3. Analyzing Changxing County as a typical case study, firstly, according to the above-mentioned influencing factor analysis framework, data were collected from official policy documents, relevant literature, authoritative news reports and other sources to systematically sort out the specific policy measures of Changxing County's chronic disease health management services; secondly, through purposive sampling method, semi-structured personal in-depth interviews were conducted with 16 policy makers, medical staff and patients related to chronic disease health management services in Changxing County, to understand what measures Changxing County has taken for each influencing factor in the previous influencing factor framework, and further explore the actual role and influence mechanism of each influencing factor.

Results:

This study extracted the influencing factors of chronic disease health management services and constructed an analytical framework of influencing factors of chronic disease health management services, which includes 3 categories (demand factors, supply factors and governance factors), 9 main categories (primary health personnel, service provision mode, infrastructure, etc.), 18 influencing factors (coverage range, personnel number, information construction, supervision and assessment, collaboration and integration, etc.). The framework was evaluated and modified by expert consultation method. The expert opinions mainly focused on three aspects: deleting duplicate or supplementing missing items, standardizing language expression, merging or splitting vague items.

Changxing County has taken a series of effective measures in carrying out free physical examination screening, group-based provision of grid-based health management, information platform construction, normalized training of primary health personnel and so on, which have improved the quality and efficiency of chronic disease health management services and realized the full-process closed-loop management of "two chronic diseases". But there are still some challenges in normalizing special fund guarantee, improving performance appraisal and incentive mechanism.

Cconclusion:

This study found that providing high-quality and efficient chronic disease health management services should take into account and focus on the influencing factors from three aspects: demand factors, supply factors and governance factors. Among them, demand factors determine the cognition and utilization of residents and patients for services; supply factors such as personnel, facilities and service modes directly affect the content, quality and effect of services; governance factors such as government attention degree, fund guarantee and supervision incentive mechanism affect the actual effect and efficiency of services. It is suggested that targeted intervention measures should be taken according to the needs and characteristics of different groups for weak links and key groups; digital information construction should be strengthened to form a closed loop of health management; existing resources should be coordinated and integrated to give play to the advantages of medical consortiums; group-based provision of grid-based health management services; fund guarantee mechanism and performance appraisal incentive mechanism should be improved. This study provides theoretical basis and practical reference for improving the quality, effect and efficiency of chronic disease health management services.