慢性肾脏疾病管理模式的探索与实践

目的探索适合农村地区慢性肾脏病(CKD)管理模式。方法通过对农村居民和基层医务人员CKD知识情况的调查,由肾科专家及基层医院全科医生协商制订并建立基层卫生院-综合医院CKD一体化管理模式,内容主要有:CKD分层管理制度,知识培训,健康宣传教育,CKD筛查、转诊和治疗等。观察实施期间转诊的126例CKD患者平均住院时间、人均总费用、人均药费、再住院率和病情恶化率。结果实施管理前后居民CKD知识知晓率提高,就医满意度由73.75%升至92.75%(P0.05)。管理前后基层医务人员CKD相关知识知晓率提高(P0.05)。CKD患者平均住院时间(11.6±1.2)d,人均总费用(3023±176)元,再住院率17.92%,病情恶化率4.76%,均低于对照组(P0.05)。治疗稳定后转回率为80.95%。结论建立CKD的基层卫生院-综合医院一体化管理模式,可提高CKD知晓率,是解决农村看病难的一种方法 。

Exploration and Practice of Management Model for Chronic Kidney Disease

Objective To explore the management model of chronic kidney disease （CKD） suitable for rural population. Methods After investigation on knowledge status of CKD among rural residents and rural medical staff, the nephrologists and the general practitioners form primary hospitals consulted together to develop and establish a integrated CKD management model for both primary hospitals and general hospitals, mainly included： Hierarchical management system for CKD, Knowledge training, health promotion and education, CKD screening, referral system, and treatment, etc. In this study, the average length of stay, total costs per capita, average expense of medicine per capita, re-hospitalization rate and the rate of disease progression were observed. Results After the implementation of the management model, the awareness rate of CKD in 400 residents significantly increased, levels of satisfaction about medical care rose from 73.75% to 92.75% （P〈0.05）. The awareness rate of CKD in 100 rural medical staff showed a significant increase （P〈0.05）. For those 126 transferred CKD patients, their the average hospital stay was （11.6± 1.26）days, average total cost of（ 3 023±176） yuan, re-hospitalization rates 17.92%, disease progression rate 4.76%, all were significantly lower than those in the control group （P〈0.05）. 102 （80.95%） patients transferred back to primary hospital after the disease was stable. Conclusion The integrated CKD management model for general hospitals and primary health centers can increase the awareness rate of CKD and coverage treatment rates. It is a good system to solve the problem of inadequate and unaffordable medical services in rural areas.