慢性肾脏病“全-专”结合管理模式探讨

Discussions Concerning the Generalist-Specialist Combination Management Model of Chronic Kidney Disease

近年来,慢性肾脏病(chronic kidney disease, CKD)患者的有效管理越来越受到关注,我院自2014年起建立了一套CKD“全-专”结合管理流程,即联合周边6个社区卫生服务中心(区内约有65万常住人口)的全科医师,成立由医师、护士组成的管理小组,制定患者随访、档案管理、筛查、风险评估、检查治疗、营养和运动、双向转诊等管理规范;通过开展专题讲座和病例讨论培训社区医师,十年来举办了7期国家级继续医学教育学习班,共培训约1 400人;定期对患者进行科普宣教;成立4个社区培训中心,糖尿病肾病等6个专病管理中心;通过建立老年体检数据库(目前已纳入26 000人)、老年社区CKD横断面调查数据库和老年CKD信息管理系统对老年CKD患者的危险因素进行回顾性分析。经过十年管理实践,我院的CKD专科管理制度化和规范性得到了提升;同时扩大了管理队伍,管理基地由医院扩大到社区;提高了社区卫生服务中心对于慢性肾病管理的水平,也提高了社区全科医师的临床专科水平;使社区CKD患者能得到早筛查、早治疗,并获得有效方便的随访和转诊,改善生活质量;有糖尿病、高血压和肌少症等一些并发症的患者能获得更精准治疗。这说明开展“全-专”结合CKD一体化管理有其必要性,值得进一步发展和完善。

In recent years,the effective management of patients with chronic kidney disease(CKD)is gaining growing attention.In 2014,our hospital established the CKD generalist-specialist combination management model,which incorporates a set of CKD management processes.The generalist component incorporates the following,general practitioners from 6 community health centers in the surrounding areas(with about 650000 permanent residents in the region)joining hands,setting up a management team composed of doctors and nurses,and formulating management protocols for patient follow-up,patient record management,screening,risk assessment,examination and treatment,nutrition and exercise,and two-way referrals.The specialist component of the model incorporates the following,providing trainings for general practitioners in the in the community in the form of lectures on special topics and case discussion sessions,and organizing 7 national-level workshops for continuing medical education in the past decade,covering about 1400 participants.In addition,regular meetings of the support groups of patients with renal diseases were organized to carry out information and education activities for patients.We have set up 4 community-based training centers and 6 specialized disease management centers,including one for diabetic nephropathy.We have retrospectively analyzed the risk factors of elderly CKD patients by establishing the elderly physical examination database(which has a current enrollment of 26000 people),the elderly community CKD cross-sectional survey database,and the elderly CKD information management system.After 10 years of management practice,the level of institutionalization and standardization of CKD specialty management in our hospital has been improved.Moreover,we have expanded the management team and extended the management base from the hospital to community.We have improved the level of CKD management in community health centers and improved the specialty competence of the general practitioners in the communities.The generalist-specialist combination management model makes it possible for CKD patients to receive early screening and treatment,obtain effective and convenient follow-up and referral services,and improve their quality of life.Patients with complications such as diabetes,hypertension,and sarcopenia could access treatments with better precision.It is necessary to carry out the generalist-specialist integrated management of CKD,which is worthy of further development and improvement.