基于家庭医生制度及分级诊疗制度的慢性肾脏病干预效果分析  

Analysis on Intervention Effects of Chronic Kidney Disease Based on Family Doctor System and Hierachical Diagnosis System

作　　者：齐郑[1] 潘洪波[1] 刘帅[1] 陈霞 韩鹏 QI Zheng;PAN Hong-bo;LIU Shuai(Huacao Community Health Service Center,Minhang District,Shanghai,201107,China)

机构地区：[1]上海市闵行区华漕社区卫生服务中心,上海201107 [2]上海市闵行区中心医院,上海201100

出　　处：《中国初级卫生保健》2020年第3期25-27,共3页Chinese Primary Health Care

基　　金：上海市闵行区自然科学研究课题(2018MHZ075)。

摘　　要：目的探讨分级诊疗模式下家庭医生转诊对慢性肾脏病的干预效果,旨在进一步提升对社区慢性肾脏病的干预策略。方法选取2016年9月—2017年8月上海市闵行区华漕社区卫生服务中心收治的60岁及以上慢性肾脏病及疑似患者为转诊组(n=55),进行尿蛋白肌酐比(ACR)及血清肌酐(SCR)检测,通过CKD-EPI公式计算出估算的肾小球滤过率(e GFR),对其进行3个月、12个月上述指标变化的比较,同时将存在上述指标异常未进行转诊的患者作为对照组(n=52),进行SCR、eGFR初始及12个月ACR比较。结果转诊组患者3个月、12个月ACR和eGFR较原始值均有相应改善,对照组较转诊组呈加重趋势。结论通过转诊前后及与未转诊组ACR、e GFR指标比较,分级诊疗模式下家庭医生转诊对于CKD的早发现、控制和延缓有积极干预效果。OBJECTIVE To explore the intervention effect of family doctor referral on chronic kidney disease under the grading diagnosis and treatment mode,aiming to further improve the intervention strategy for chronic kidney disease in the community.METHODS From September 2016 to August 2017,chronic kidney disease and suspected patients aged 60 years and above who are admitted to Huacao Community Health Service Center in Minhang District of Shanghai were transferred to the referral group(n=55).The urine protein creatinine ratio(ACR)and serum creatinine(SCR)are measured.The estimated glomerular rate filtration(EGFR)is calculated by CKD-EPI formula,and the changes of the above indexes are compared for three months and one year,while the patients without referral are compared with the control group(n=52).RESULTS The ACR and EGFR of the patients in the referral group are improved in3 months and 1 year compared with the original values,while the control group is more severe than the referral group.CONCLUSION Compared with the ACR and eGFR indicators before and after referral,the referral of family doctors in the graded diagnosis and treatment mode has positive effects on the early detection,control and delay of CKD.

关 键 词：分级诊疗 家庭医生 慢性肾脏病 干预 

分 类 号：R197[医药卫生—卫生事业管理]