慢性肾脏病患者智能健康随访管理系统的构建及应用

Construction and application of intelligent health follow-up management system for patients with chronic kidney disease

目的基于慢性病管理模型构建智能健康随访管理系统,并评价其在慢性肾脏病患者中的应用效果。方法选取浙江省某三级甲等医院肾内科出院的慢性肾脏病患者172例,根据出院时间将患者分为对照组86例和观察组86例,对照组进行常规随访,观察组通过组建团队、搭建系统架构、建立专病数据库及开发应用模块构建的智能健康随访管理系统随访。干预6个月后比较两组自我管理能力、肾小球滤过率、血肌酐、尿微量白蛋白肌酐比值、收缩压、舒张压、BMI的差异。结果对照组84例、观察组85例完成研究。干预6个月后观察组自我管理能力评分显著高于对照组,肌酐、尿微量白蛋白肌酐比值、收缩压、舒张压、BMI值显著低于对照组(均P<0.05);干预前后两组肾小球滤过率比较无统计学差异(P>0.05)。结论基于慢性病管理模型的智能健康随访管理系统能提高慢性肾脏病患者的自我管理能力,延缓慢性肾脏病的进展。

Objective To construct an intelligent health follow-up management system based on the Chronic Care Model,and to eva-luate its application effect in patients with chronic kidney disease.Methods A total of 172 patients with chronic kidney disease discharged from the renal department of a tertiary hospital in Zhejiang province were selected.According to the discharge time,the patients were divided into control group and observation group with 86 cases each.The control group was followed up as usual,while the observation group was followed up through the establishment of a intelligent health follow-up management system by forming a team,building a system architecture,establishing a special disease database,and developing application modules.After 6 months of intervention,the differences in self-management ability,estimated glomerular filtration rate(eGFR),blood creatinine,urine microalbumin creatinine ratio(ACR),systolic blood pressure,diastolic blood pressure and BMI were compared between the two groups.Results There were 84 cases in the control group and 85 cases in the observation group completed the study.After 6 months of intervention,the self-management ability score of the observation group was significantly higher than that of the control group,and the values of creatinine,ACR,systolic blood pressure,diastolic blood pressure,and BMI were significantly lower than those of the control group(all P<0.05);there was no statistically significant difference between the eGFR of the two groups before and after the intervention(P>0.05).Conclusion Intelligent health follow-up management system based on chronic disease management model can improve the self-management ability in patients with chronic kidney disease and delay the progression of chronic kidney disease.