天津市基层慢病管理中心实施慢病管理服务模式的效果分析

Performance of the chronic disease management service model implemented by the Tianjin grassroots chronic disease management centers

目的梳理天津市基层慢病管理中心的建设模式及实施慢病管理服务模式后取得的效果,从而提出进一步改进建议。方法在天津市16个区中,选取市内城区、环城郊区、远郊区各1个区作为研究样本,采集实施慢病管理服务模式后,2023年1月—12月期间以区为单位的基层慢病管理中心糖尿病患者随访情况、规范管理率等过程和效果指标及其变化情况进行统计分析。结果基层慢病管理中心共运行47家,累计随访糖尿病患者8.1万余例次,开具8.8万张健康管理处方,完成6.8万例次糖尿病并发症筛查,3个区的糖尿病签约患者转诊率平均降幅为10.54%。规范管理率、糖化血红蛋白检测率、血脂检测率和并发症筛查率均有提升,3个区的并发症筛查率均在90%以上。血糖控制率、糖化血红蛋白达标率、血压和血脂达标率等健康结果指标均逐步提升。结论基层慢病管理中心对于提升基层医疗服务能力,推进医防融合建设具有一定效果。今后尚需进一步提升管理同质化水平,加强慢病管理中心团队建设,关注慢病管理中心服务团队的积极性,创新激励机制,促进慢病管理中心进一步发展完善。

Objective To elucidate the construction model of the grassroots chronic disease management center in Tianjin and examine the outcomes achieved following the implementation of the chronic disease management service model,aiming to provide recommendations for its further improvement.Methods Among the 16 districts/counties in Tianjin,one district each was selected from the central areas,near suburbs,and far suburbs as the sampling district.The process and performance indicators including follow-up and standardized management of diabetic patients at grassroots chronic disease management centers in these districts from January to December 2023 were statistically analyzed.Results A total of 47 grassroots chronic disease management centers were operated,at which over 81,000 diabetic patients were followed up,for whom 88,000 health management prescriptions were issued and 68,000 diabetes complication screenings were conducted.There was an average reduction of 10.54%in the referral rate of contracted diabetic patients.The standardized management rate,glycosylated hemoglobin detection rate,blood lipid detection rate,and complication screening rate were raised.Specifically,the complication screening rate exceeded 90%in all three districts.Health outcome indicators,including glycemic control rate,glycosylated hemoglobin compliance rate,blood pressure and blood lipid compliance rates,have been progressively improved.Conclusion Grassroots chronic disease management centers play a role in enhancing the capacity of grassroots medical services and advancing the integration of medical care with preventive efforts.In the future,it is essential to advance the homogeneous management,train chronic disease management teams,foster the motivation of medical,and introduce innovative incentive mechanisms,thus propelling the continued advancement and optimization of chronic disease management centers.