“互联网+”程序化随访方案在肾移植受者中的管理研究

  目的  探讨将“互联网+”与程序化随访方案以手机APP微信端为载体进行深度融合，对肾移植受者实施专业化、规范化、持久化、个性化及程序化的随访管理所取得的临床效果。  方法  选取温州医科大学附属第一医院移植中心行首次肾移植成功的79例肾移植受者为研究对象，按入院时间先后顺序，将2019年1—12月采用常规随访方式管理的40例肾移植受者作为常规组；将2020年1—12月实施“互联网+”程序化随访方案管理的39例肾移植受者作为干预组。对2组肾移植受者干预前后自我管理能力及生活质量评分进行对比分析。  结果  干预后干预组肾移植受者饮食管理、躯体活动管理、治疗管理及社会心理管理4个维度自我管理能力总评分[(106.58±17.73)分]与常规组[(83.77±14.70)分]比较，差异有统计学意义(t=6.232，P＜0.001)；干预后干预组肾移植受者生理功能、心理职能、社会功能、疾病治疗等生活质量总评分[(150.77±14.50)分]与常规组[(130.26±12.72)分]比较，差异有统计学意义(t=6.688，P＜0.001)。  结论  将“互联网+”与程序化随访方案以手机APP微信端为载体进行深度融合，对肾移植受者实施专业化、规范化、持久化、个性化及程序化的随访管理，能够有效提升肾移植受者的自我管理能力及生活质量。 

Management of "Internet plus" procedural follow-up program in renal transplant recipients

  Objective  To explore the clinical effect of "Internet plus" procedural follow-up program in mobile phone APP WeChat terminal for deep integration, and to achieve the professional, standardized, durable, personalized and programmed follow-up management for renal transplant recipients.  Methods  According to the order of admission time, 79 renal transplant recipients who successfully underwent first kidney transplantation in our hospital were selected as the research objects. Forty renal transplant recipients who received routine follow-up from January to December 2019 were selected as the routine group, whereas 39 renal transplant recipients who were followed up by the "Internet plus" procedural follow-up program from January to December 2020 were selected as the intervention group. The self-management ability and quality of life scores of both groups before and after intervention were compared and analysed.  Results  After the intervention, the total score of self-management ability in the four dimensions of diet management, physical activity management, treatment management and social psychological management in the intervention group was (106.58±17.73) points, and that in the routine group was (83.77±14.70) points. The difference was statistically significant (t=6.232, P < 0.001). After the intervention, the total score of physiological function, psychological function, social function and disease treatment of renal transplant recipients in the intervention group was (150.77±14.50) points, and that in the routine group was (130.26±12.72) points, the difference was statistically significant (t=6.688, P < 0.001).  Conclusion  The "Internet plus" procedural follow-up program are deeply integrated with the WeChat APP as the carrier, professional, standardised, lasting, personalised and procedural follow-up management was implemented for renal transplant recipients. They can effectively improve the self-management ability and quality of life of renal transplant recipients.