多学科协作联合移动医疗用于慢性肾脏病患者管理

目的提高慢性肾脏病(CKD)非透析患者自我管理能力,延缓疾病进展。方法将420例CKD非透析患者随机分为两组各210例。对照组行常规肾内科门诊复诊与随访;观察组在此基础上采取多学科专业团队联合移动医疗实施患者管理,包括设计CKD患者管理App,建立患者电子档案,多学科协作团队同时出诊,线上线下咨询与指导等。实施12个月后评价效果。结果完成全程研究者观察组208例、对照组200例。干预6个月、12个月时,观察组自我管理行为评分,收缩压达标率显著高于对照组(均P<0.01);肾小球滤过率、血肌酐值显著优于对照组(均P<0.01)。结论采用多学科协作联合移动医疗针对CKD非透析患者进行持续管理,有利于培养患者自我管理能力,延缓疾病进展。

Multidisciplinary collaboration combining mobile medical technology for the management of patients with chronic kidney diseases

Objective To improve self-management ability of non-dialysis patients with chronic kidney diseases (CKD) and to slow the progression of disease. Methods A total of 420 non-dialysis CKD patients were randomly divided into two groups, with 210 in each. The control group received routine outpatient counselling and follow-up, while the intervention group was subjected to multidisciplinary care including designing a mobile application, establishing electronic health archives, and providing online and face-to-face counselling. The effect was evaluated after 12 months of implementation. Results Two hundred participants in the control group and 208 in the intervention group completed the study. Self-management behavior score, rate of systolic blood pressure control, and the glomerular filtration rate were significantly higher, whereas the concentration of serum creatinine was significantly lower in the intervention group than those in the control group at 6 and 12 months into the intervention (P<0.01 for all). Conclusion Multidisciplinary collaboration combining mobile medical technology applied in non-dialysis CKD patients is beneficial to enhance self-management ability and delay disease progression.