社区-综合性医院二级全科医生管理多病共存慢性病的效果

To explore the effect of two-level general practitioner’s management on the patients with multiple chronic non-communicable diseases in community-general hospitals under the graded diagnosis and treatment model

目的 探讨分级诊疗模式下社区-综合性医院二级全科医生管理对多病共存慢性病管理效果。方法收集2017年7月至12月经社区医生管理半年后仍未达标转诊到综合性医院全科慢性病管理门诊的多种慢性病共存的患者(主要合并高血压、糖尿病、高脂血症),共纳入受试者300例,在综合性医院各临床专科力量支持下由综合性医院全科医疗科和社区全科医生分层进行综合管理,建立起综合医院与社区服务中心二级分工的合作机制。定期随访血压、血糖、血脂,同时对患者进行健康教育、心理方面指导。随访1年后对患者进行健康状况评估(采用健康调查简表SF-36)。结果受试者治疗前后血压、血糖、血脂控制明显好转,血压、血糖自我管理能力明显提升,医疗费用明显下降,差异均有统计学意义(P均<0.05);治疗后健康状况明显好转,与治疗前对比差异有统计学意义(P<0.05)。结论多病共存的慢性病通过社区-综合性医院二级全科医生分层管理,确保患者得到持续性、综合性、个体化的全程照顾,能够明显改善患者治疗效果以及健康状况,改善患者长期预后。

Objective To explore the effect of two-level general practitioner’s management on multiorbidity) in community-general hospitals under the graded diagnosis and treatment model. Methods A total of 300 patients with multiple chronic diseases (including hypertension,diabetes and hyperlipidemia)who were referred to our general practice chronic disease management clinic from July 2017 to December 2017 after being managed by community doctors for half a year were enrolled in this study.With the support of various clinical specialists in our hospital,the general practice and community general practitioners of our hospital were stratified and integrated management was established.The cooperative mechanism of secondary division of labor between general hospitals and community service centers has been established.Regular follow-up of blood pressure,blood sugar,blood lipids,and health education,psychological guidance for patients.The health status of the patients was evaluated after 1 year follow-up (SF-36). Result The subjects′blood pressure,blood sugar and blood lipid control improved significantly,and there were significant statistical differences ( P< 0.05);blood pressure and blood sugar self-management ability improved significantly,and there were statistical differences ( P< 0.05);medical expenses decreased significantly,and there were statistical differences before and after treatment ( P< 0.05);health status assessment,and health after treatment.The health condition improved significantly,and there was statistical difference between before and after treatment ( P< 0.05). Conclusion Chronic diseases coexisting with multiple diseases can be managed by two-level general practitioners in community-general hospitals to ensure that patients receive sustained,comprehensive and individualized whole-course care,which can significantly improve the treatment effect and health status of patients,and improve long-term prognosis of patients.