基于慢性肾脏病（CKD）管理的精准分级诊疗应用实践

• 作者： 朱海燕, 王朝昕, 孙万驹 ¹
• 作者单位：
  1.  上海市浦东新区人民医院上海交通大学医学院公共卫生学院上海市浦东新区人民医院
• 提交时间：2022-09-13

摘要: 背景 分级诊疗制度是优化基本医疗卫生制度的重要步骤，但落地实施时遇到阻碍，因存在转诊标准不一、空间不连贯和时间滞后等问题，医联体模式推进存在难度。目的 遴选区域高发病种慢性肾脏病（CKD），探索建立CKD医联体精准分级诊疗系统并进行实证应用评价。方法 以慢性肾脏病（CKD）病种为例，基于指南梳理CKD患者的疾病管理规律，建立医疗信息联通共享、转诊规则标准的CKD双向转诊知识库，设计区域CKD专病分级诊疗信息系统流程，构建基于医院—社区联动管理的专病分级诊疗一体化管理模型。结果 研发CKD专病分级诊疗系统，以信息化为支撑推进区域医疗资源整合和上下联动，形成从早期筛查、诊断提醒、专病治疗到持续随访跟踪贯穿全生命周期的疾病管理体系，及上下联动的专病管理模式。结论 基于CKD知识库的专病分级诊疗模式，可以精准定位易发和高危人群，及时筛查评估CKD早期患者，提升CKD患者的健康管理和诊疗效率。

Abstract: Background The graded diagnosis and treatment system is an important step to optimize the basic medical health, but it encounters obstacles in its implementation. Due to the problems of different referral standards, spatial discontinuity and time lag, it is difficult to promote the medical consortium model. Objective The study aims to select regional dominant diseases about chronic kidney disease (CKD) , explore and establish a regional hierarchical treatment system to conduct empirical evaluation. Methods The hospital took chronic kidney disease (CKD) as an example to sort out the disease management rules of CKD patients that based on clinical guidelines, establish a two-way referral knowledge base of CKD with medical information sharing and referral rules, design the process of regional CKD specific disease classification diagnosis and treatment information system, and build an integrated management model of specific disease classification diagnosis that based on hospital community linkage management. Results The study developed a classified diagnosis and treatment system for CKD that promoted the integration of regional medical resources and the upper and lower linkages with the support of informatization. It established a disease management system that run through the whole life cycle from early screening, diagnosis reminder, specific disease treatment to continuous follow-up and tracking as well as a specific disease management mode. Conclusion The classified diagnosis and treatment mode based on CKD knowledge base can accurately locate vulnerable and high-risk population, timely screen and evaluate early CKD patients to improve the health management and diagnosis and treatment efficiency.

• 分类： 医学、药学 >> 基础医学
• 引用： ChinaXiv:202209.00114 (或此版本 ChinaXiv:202209.00114V1)
  DOI:10.12114/j.issn.1007-9572.2022.0643
  CSTR:32003.36.ChinaXiv.202209.00114.V1
• 推荐引用方式： 朱海燕, 王朝昕, 孙万驹.(2022).基于慢性肾脏病（CKD）管理的精准分级诊疗应用实践.中国全科医学.doi:10.12114/j.issn.1007-9572.2022.0643 (点此复制)