Abstract:

Background

In 2019, the National Health Commission launched the construction of compact county medical alliance to strengthen chronic diseases management in primary care, and the construction of chronic disease management models varies among county medical alliance sites. Xindu District, as one of the first national compact county medical alliance sites in Sichuan Province, has explored both dimensions of theoretical and practical innovation in the construction of the innovative model of chronic disease management in compact county medical alliance with treatment-prevention integration, providing a new approach for the innovative development of primary compact county medical alliance in China.

Objective

To analyze the innovation model and its effectiveness of chronic disease management in compact county medical alliance with treatment-prevention integration of Xindu District with the experience of international integrated medical models.

Methods

The chronic disease management in compact county medical alliance with treatment-prevention integration of Xindu District was constructed with "one center, two integration, three reforms and four safeguard mechanisms" under the leadership of Xindu District Health Bureau, to strengthen the management of chronic diseases mainly including hypertension and diabetes.

Results

As of June 2022, the number of hypertension or diabetes patients under standardized management in the district increased by 50.87% compared with the initial stage of construction, the number of hypertension or diabetes patients increased by 55.28% and 49.04%, respectively; while the proportion of patients with HbA1c<7% or BP<140/90 mmHg (1 mmHg=0.133 kPa) increased by 70.69% and 115.28% in the past year among them, respectively. The outpatient visits of primary care increased by 14.30% in one year, among which the outpatient visits for hypertension or diabetes increased by 36.01%; while downward referrals within medical communities increased by 14.55%, creating a number of demonstration units for the transformation of treatment-prevention integration in primary care.

Conclusion

The innovative model of chronic disease management in compact county medical alliance with treatment-prevention integration of Xindu District has a significant effect on improving the quality and efficiency of chronic disease management in primary care.

Key words: Treatment-prevention integration, Medical alliance, International integrated care models, Chronic disease, Disease management

摘要：

背景

2019年國(guó)家衛(wèi)生健康委啟動(dòng)了緊密型縣域醫(yī)共體的建設(shè)工作，以強(qiáng)化基層慢性病管理，各縣域醫(yī)共體試點(diǎn)慢性病管理模式構(gòu)建情況不盡相同。新都區(qū)作為四川省首批國(guó)家緊密型縣域醫(yī)共體建設(shè)試點(diǎn)縣之一，在醫(yī)防融合慢性病管理創(chuàng)新模式的構(gòu)建過(guò)程中進(jìn)行了理論創(chuàng)新和實(shí)踐創(chuàng)新兩個(gè)維度的探索，為我國(guó)基層緊密型醫(yī)共體的創(chuàng)新發(fā)展提供了一種思路。

目的

結(jié)合國(guó)際整合型醫(yī)療模式的經(jīng)驗(yàn)，分析新都區(qū)緊密型縣域醫(yī)共體醫(yī)防融合慢性病管理創(chuàng)新模式及其成效。

方法

2019年6月至2022年6月，新都區(qū)在區(qū)衛(wèi)生健康局牽頭下，構(gòu)建了"1個(gè)中心，2個(gè)整合，3個(gè)變革，4個(gè)保障"的醫(yī)防融合慢性病管理模式，強(qiáng)化以高血壓、糖尿病為主的慢性病管理工作。

結(jié)果

截至2022年6月，全區(qū)高血壓、糖尿病規(guī)范化管理人數(shù)較建設(shè)初期增長(zhǎng)50.87%；其中糖尿病、高血壓管理人數(shù)分別增長(zhǎng)55.28%、49.04%；糖尿病患者中糖化血紅蛋<7%的人群比例、高血壓患者中血壓<140/90 mmHg（1 mmHg=0.133 kPa）的人群比例也在近1年內(nèi)分別增長(zhǎng)了70.69%、115.28%；全區(qū)基層門(mén)診量在一年內(nèi)增長(zhǎng)了14.30%，其中高血壓、糖尿病的門(mén)診量增長(zhǎng)達(dá)36.01%；1年內(nèi)醫(yī)共體內(nèi)下轉(zhuǎn)患者增長(zhǎng)了14.55%；并打造了一批基層醫(yī)防融合轉(zhuǎn)型示范單位。

結(jié)論

新都區(qū)緊密型縣域醫(yī)共體醫(yī)防融合的創(chuàng)新型慢性病管理模式，對(duì)基層慢性病管理提質(zhì)增效有明顯效果。

關(guān)鍵詞: 醫(yī)防融合, 醫(yī)共體, 整合醫(yī)療, 慢性病, 疾病管理

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