持续质量改进对慢性肾脏病3～4期患者肾功能预后的影响

Effect of continuous quality improvement on renal function in patients with chronic kidney disease of stage 3-4

目的应用持续质量改进(CQI)方法建立对慢性肾脏病(CKD)3~4期患者的管理模式,并且探讨CQI对CKD患者肾功能预后的影响。方法选择在上海市静安区闸北中心医院肾内科CKD专病门诊定期随访的86例CKD患者(3期50例,4期36例)。将患者随机分为观察组和对照组,每组43例。观察组应用PDCA四步法,即设计(plan)―实施(do)―检验(check)―应用(act),采取医疗干预和健康教育相结合的模式;对照组采取医疗干预的传统管理模式。两组均每月随访1次,随访时间为1年,以血清肌酐(Scr)水平翻倍或进入终末期肾病、发生心脑血管事件为观察终点。比较两组按时随访率、估算的肾小球滤过率(e GFR)和Scr水平。结果 (1)观察组平均随访次数为(10.7±2.8)次,按时随访率为(89.9±12.8)%,对照组平均随访次数为(4.1±2.2)次,按时随访率为(34.2±4.9)%,两组间差异有统计学意义(P均<0.01)。(2)在1年随访期内,观察组无终点事件发生;对照组有2例进入终末期肾病,1例发生急性心绞痛。(3)实施CQI前,两组间的e GFR、Scr水平差异均无统计学意义(P均>0.05)。观察组实施CQI后的e GFR为(39.35±12.23)m L/(min·1.73 m2),高于观察组实施CQI前的(37.22±11.02)m L/(min·1.73 m2)和对照组实施CQI后的(35.04±12.31)m L/(min·1.73 m2),差异均有统计学意义(P均<0.05);Scr水平为(139.25±14.15)μmol/L,低于观察组实施CQI前的(145.16±15.41)μmol/L和对照组实施CQI后的(148.06±15.63)μmol/L,差异均有统计学意义(P均<0.05)。结论应用CQI管理方法,采取医疗干预和健康教育相结合的模式,可以改善CKD 3~4期患者的肾功能,减少终末期肾病和心脑血管事件的发生率。

Objective To establish a management mode for patients with chronic kidney disease（CKD） of stage 3 to 4 by continuous quality improvement（CQI）, and to observe the effect of CQI on renal function in CKD patients. Methods A total of 86 patients with CKD（50 in stage 3 and 36 in stage 4） were enrolled in this study, and they were regularly followed-up in the CKD outpatient of the Department of Nephrology of Jing＇an District Zhabei Centre Hospital of Shanghai. The patients were randomly divided into observation group and control group, with 43 cases in each group. In the observation group, we used the management mode combining medical intervention and health education by plan-do-check-act（PDCA） four-step method; in the control group, we used the traditional management mode of medical intervention. All the patients were followed up once a month for one year. The end points included doubling serum creatinine（Scr） or entering end-stage renal disease, and occurence of cardiovascular and cerebrovascular events. The follow-up on time rate（%）, Scr level, and estimated glomerular filtration rate（e GFR） were compared between the two groups. Results In the observation group, the average follow-up times were 10.7±2.8 and the follow-up on time rate was（89.9±12.8）%; while those were 4.1±2.2 and（34.2±4.9）% in the control group, and there were significant differences between the two groups（all P〈0.01）. During the 1-year follow-up period, two cases had end-stage renal disease and one case had acute angina in the control group, while no end point was found in the observation group. Before the implementation of CQI, there were no significant differences in e GFR or Scr level between the two groups（all P〈0.05）. The e GFR of the observation group after implementation of CQI was（39.35±12.23） m L/（min · 1.73 m2）, which was significantly higher than those of the observation group before implementation（[37.22±11.02] m L/[min · 1.73 m2], P〈0.05） and the control group after implementation（[35.04±12.31] m L/[min · 1.73 m2], P〈0.05）. The Scr level of the observation group after implementation of CQI was（139.25±14.15） μmol/L, which was significantly lower than those of the observation group before implementation（[145.16±15.41] μmol/L, P〈0.05） and the control group after the implementation（[148.06±15.63] μmol/L, P〈0.05）. Conclusion CQI management method with the combination of medical intervention and health education can improve the renal function of patients with CKD stages 3-4, and reduce the incidence of end-stage renal disease and cardiovascular and cerevascular events.