多方协作的立体化农村慢性病管理模式探索与实施效果评价

Exploration and practice of a rural chronic disease management model based on three-dimensional multipartite cooperation

目的探索多方协作的立体化农村慢性病管理模式,并评价其实施效果。方法于2013年以河池市小长安镇卫生院为基础建设慢性病管理的团队,完善慢性病健康管理方案,协同、组织村医开展慢性病管理业务,并依靠深圳市福田区慢性病防治院的帮扶及各村委支持,创新农村慢性病管理模式。结果2014~2018年,小长安镇的慢性病健康管理水平和管理效果较以往有明显提升,全镇居民建立健康档案和纳入管理数从17899人增加到25040人,建档率提高23.20%。高血压和糖尿病的规范管理人数分别从2014年的1201人、156人上升到2018年的2158人、238人。高血压和糖尿病的规范管理率分别提高了10.87%和1.15%;血压、血糖的规范管理达标率分别提高了25.29%和26.33%,规范管理满意率分别提高了21.38%和29.77%。结论小长安镇建立的多方协作的立体化农村慢性病管理模式在糖尿病和高血压的疾病控制方面取得了满意的效果,值得在中国农村地区的慢性病管理工作中推广。

Objective To explore a rural chronic disease management model based on three-dimensional multipartite cooperation and evaluate its implementation effect.Methods In 2013,a chronic disease management team was established based on Xiaochang′an Town Health Center in Hechi City to improve the health management plan for chronic diseases,to coordinate and organize the village doctors to carry out the chronic disease management business,and to innovate the rural chronic disease management mode with the help of the Chronic Disease Prevention and Treatment Hospital of Futian District in Shenzhen City and the support of the village committee.Results From 2014 to 2018,the health management level and management effect of chronic diseases in Xiaochang′an Town were significantly improved compared with those before 2014.The number of the residents who were established health files and were incorporated management in the town increased from 17899 to 25040,and the filing rate increased by 23.20%.The number of the residents receiving standardized managements of hypertension and diabetes increased from 1201 and 156 in 2014 to 2158 and 238 in 2018,respectively.The normative management rates of hypertension and diabetes increased by 10.87%and 1.15%respectively.The normative management rates of blood pressure and blood sugar reaching standard increased by 25.29%and 26.33%,and the standard management satisfaction rates increased by 21.38%and 29.77%,respectively.Conclusion The multipartite collaborative three-dimensional rural chronic disease management model established in Xiaochang′an Town has achieved satisfactory results in the disease control of diabetes and hypertension,and is worth promoting in the management of chronic diseases in rural areas in China.