苏州市相城区慢性阻塞性肺疾病区域一体化管理模式探索与实践

Exploration and Practice of Regional Integrated Management Mode of Chronic Obstructive Pulmonary Disease in Xiangcheng District of Suzhou

目的:探索苏州市相城区慢性阻塞性肺疾病区域一体化管理模式实施效果。方法:由苏州市相城区卫生健康委员会组织11家公立医院医护人员组成呼吸专科联盟,建立统一的慢阻肺信息化管理平台,进行慢阻肺区域一体化管理。通过对呼吸专科联盟医护人员的慢阻肺管理相关知识、初筛肺功能仪、吸入药物使用、肺康复等技能培训,提升基层医院慢阻肺管理水平,加强科室建设,并组织进社区慢阻肺宣传、肺功能筛查等。结果:与项目运行前相比,项目运行满1年后,基层医务人员慢阻肺知识以及管理水平、肺功能操作、判读能力明显提高,差异有统计学意义(P<0.05);基层医院慢阻肺管理设备、药品数量明显提升,差异有统计学意义(P<0.05);宣传受众人数提高4倍,肺功能筛查人数提高7倍,肺康复指导人次提高7倍。在一体化管理平台进行同质化管理的524例慢阻肺患者中,急性加重住院次数、慢阻肺相关医疗费用明显减少,治疗依从性明显提高,差异有统计学意义(P<0.05)。结论:慢阻肺区域一体化管理模式可以利用上级医院的技术优势,快速提升基层医务人员的慢阻肺管理能力,利用基层医务人员的数量优势和区域优势,改善慢阻肺患者的管理。

OBJECTIVE To explore the effect of the chronic obstructive pulmonary disease(COPD)regional integrated manage⁃ment mode.METHODS The high-risk population and patients with COPD in the whole region were selected as the subjects.The re⁃spiratory specialty alliance was formed by the relevant medical staff of 11 public hospitals organized by the District Health and Fami⁃ly Planning Commission.A unified information management platform for COPD was established in the whole region to carry out inte⁃grated management of COPD in the region.Through training of COPD management knowledge,initial screening of pulmonary func⁃tion,inhalation drug use,pulmonary rehabilitation and other skills of alliance medical staff,the level of homogenization management of COPD was improved,department construction was strengthened,and community-based COPD publicity and pulmonary function screening were organized.RESULTS After one year of integrated management operation,the knowledge and management level of COPD of primary doctors,as well as the operation and interpretation ability of pulmonary function,were significantly improved(P<0.05).The number of COPD management equipment and drugs in primary hospitals was significantly improved(P<0.05).The num⁃ber of publicity recipients increased by 4 times,the number of pulmonary function screening increased by 7 times,and the number of pulmonary rehabilitation guidance increased by 7 times.Among the 524 patients with COPD who received homogenized manage⁃ment in the integrated management platform,the number of acute exacerbations and hospitalizations,as well as COPD-related medi⁃cal costs,were significantly reduced,and treatment compliance was significantly improved(P<0.05).CONCLUSION The regional in⁃tegrated management mode of COPD can rapidly improve the COPD management ability of primary medical staff by using the techni⁃cal advantages of higher-level hospitals.By taking advantage of the quantity and regional advantages of primary personnel,it can im⁃prove the management of patients with COPD.