Chronic Kidney Disease Linkage Management Hierarchical Diagnosis and Treatment
常州市科学技术局支撑（社会发展）项目（CE20215024）
目的：对以三级综合医院为主导的“1+N”慢性肾脏病（CKD）联动管理模式进行效果评价，探索有效的CKD分级诊疗管理措施。方法：对开展“1+N”CKD联动模式前后的基层首诊、上下转诊、基层随访、医务人员及社区居民CKD知晓率、满意度及分级诊疗意愿进行前后对照研究。结果：实施“1+N”联动管理后，基层首诊人数、上转患者、下转患者、基层规律随访患者明显上升，社区医务人员和居民对CKD基础知识知晓率分别上升至46.3%、32.9%，管理知识知晓率上升至44.9%、23.1%，基层就诊满意度由41.3%上升至87.1%，分级诊疗支持率由45.3%上升至95.1%。结论：以三级综合医院主导的“1+N”CKD联动管理模式，通过多举措强基层、完善分级诊疗流程，有助于推动形成“基层首诊、双向转诊，急慢分治、上下联动”的医疗模式。
Objective：To evaluate the effect of “1+N”linkage management mode of chronic kidney disease led bytertiary generalhospital，and explore effective hierarchical diagnosis and treatment management measures of chronic kidney disease. Methods：Before and after the “1+N” CKD linkage mode，the first diagnosis，referral up and down，follow-up at the primary level，the awareness rate of CKD，satisfaction rate and graded diagnosis and treatment intention of medical staff and community residents were analyzed statistically. Results：After the implementation of the “1+N” linkage management，the number of initial diagnosis，up-referral patients，down-referral patients and regular follow-up patients at the grassroots level increased significantly. The overall awareness rate of community medical staff and residents on basic knowledge of CKD increased to 46.3% and 32.9%，and the overall awareness rate of management knowledge increased to 44.9% and 23.1%. The satisfaction degree of primary-level medical treatment increased from 41.3% to 87.1%，and the support rate of graded medical treatment increased from 45.3% to 95.1%. Conclusion：The ”1+N“ linkage management of CKD led bytertiary generalhospital，through multiple measures to strengthen the grass-roots level and improve the hierarchical diagnosis and treatment process，is conducive to promoting the formation of the medical order of “first diagnosis at the grass-roots level，two-way referral，emergency and slow treatment，and linkage between the upper and lower levels”.