国家慢性病综合防控示范区高危人群和患者管理评价

Evaluation on the management of population with high risk and patients with chronic diseases in national demonstration areas for comprehensive prevention and control of chronic diseases

目的评价2011-2012年创建的2批国家慢性病综合防控示范区的高危人群发现和干预、患者管理工作情况。方法依据国家慢性病综合防控示范区考核内容,建立评价问卷,从各示范区的"工作报告"和"社区诊断报告"中提取对应指标数据,分析示范区高危人群发现与干预、患者管理2类工作内容。结果在140个示范区中,医疗机构首诊测血压指标满分率为94.3%,提供职工体检机构覆盖率指标满分率为92.9%,设立自助检测点数指标满分率为97.1%;高危人群标准知晓率指标满分率为86.4%,人群体重知晓率指标满分率为96.4%,人群腰围知晓率指标满分率为81.4%,人群血压知晓率指标满分率为78.6%;人群血糖知晓指标满分率为84.3%;高血压患者登记率指标满分率为35.0%,高血压患者规范管理率指标满分率为67.9%,高血压患者控制率指标满分率为64.3%,糖尿病患者登记率指标满分率为35.0%,糖尿病患者规范管理率指标满分率为56.4%,糖尿病患者控制率指标满分率为60.7%;辖区患者自我管理小组数指标满分率为97.1%,患者自我管理社区覆盖率指标满分率为84.3%。结论慢性病综合防控示范区工作的开展,推动了慢性病高危人群发现和干预、患者管理政策与措施的具体落实和深入开展。

Objective To evaluate the management of discovering and intervening the population with high risk in two national demonstration areas for comprehensive prevention and control of chronic diseases, which were established in 2011 and 2012. Methods According to content of examining the national demonstration areas for comprehensive prevention and control of chronic diseases, an evaluating questionnaire was designed and the corresponding data were collected from work report and community diagnosis report, and two kinds of work for discovering and intervening the population with high risk, and managing the patients with chronic diseases were analyzed. Results In 140 national demonstration areas, the full score rate of measuring blood pressure in the first medical option was 94.3%, the full score rate of organization for physical examination was 92.9%, the full score rate of auto-detection points was 97.1%, the full score rate of awareness of population with high risk was 86.4%, the full score rate of awareness of body weight was 96.4%, the full score rate of awareness of waistline was 81.4%, the full score rate of awareness of blood pressure was 78.6%, the full score rate of awareness of blood glucose was 84.3%, the full score rate of registration of patients with hypertension was 35.0%, the full score rate of standard management of patients with hypertension was 67.9%, the full score rate of controlling hypertension in patients with hypertension was 64.3%, the full score rate of registration of patients with diabetes was 35.0%, the full score rate of standard management of patients with diabetes was 56.4%, the full score rate of controlling blood glucose in patients with diabetes was 60.7%, the full score rate of patients self-management group was 97.1%, the full score rate of communities with patients self-management was 84.3%. Conclusion The establishment of national demonstration areas for comprehensive prevention and control of chronic diseases promote the discovery and intervention of population with high risk, and improve the management for patients with chronic diseases.