SMART原则在全科团队管理慢性病中的作用

The role of SMART principle in the management of chronic diseases by general practitioners

目的:探讨SMART的原则在全科团队管理慢性病中的应用。方法:选取本中心全科团队,每个全科团队都配备1名全科医生,1名护士和其他卫生技术人员组成。每个全科团队分试验组和对照组。每组2个全科团队,试验组按照SMART原则对慢性病进行管理。对照组常规对慢性病进行管理。结果:SMART组慢性病规范管理率均达到70%以上,而对照组仅30%,差异有统计学意义(P<0.05)。结论:利用SMART原则在全科团队管理慢性病中能显著提高规范管理率,降低慢性病的发生率和死亡率,提高慢性病患者的生活质量。

Objective：To explore the application of SMART in the management of chronic diseases by general practitioners.Methods：A general practitioner team was selected.Each general team was equipped with a general practitioner,a nurse and other health technicians.Each group was divided into the experimental group and the control group.Each group contains 2 general teams,the experimental group managed the chronic disease according to the SMART principle.The control group routinely managed chronic diseases.Results：The standardized management rates of chronic diseases in the SMART group were all above 70%,while those in control group were only 30%,and there as a statistically significant difference in comparison（P0.05）.Conclusion：The use of SMART principle in the management of chronic diseases in the general department can significantly improve the standardized management rate,reduce the incidence of chronic diseases and mortality,and improve the quality of life of the patients with chronic diseases.