医联体视角下构建“三全”糖尿病足闭环防治管理模式的实践与探索  

Practice and Exploration of a Closed-loop Diabetic Foot Prevention and Management Model of"Three Whole"in the Perspective of Medical Association

作　　者：周贵阳 毛海英 濮泽琼[1] 石暐 周耀宗 吴丽莎 周小勇[1] ZHOU Guiyang;MAO Haiying;Pu Zeqiong;SHI Wei;ZHOU Yaozong;WU Lisha;ZHOU Xiaoyong(Department of Medical Services,Jinshan Hospital Affiliated to Fudan University,Shanghai,201508 China;Department of Chinese Medicine Development and Science Education,Jinshan District Health and Wellness Committee,Shanghai,200540 China;Outpatient Office,Hospital of Blood Diseases of Chinese Academy of Medical Sciences,Tianjin,300020 China;Office of the Director,Shenzhen Longgang Central Hospital,Shenzhen,Guangdong Province,518038 China)

机构地区：[1]复旦大学附属金山医院医务部,上海201508 [2]上海市金山区卫生健康委员会中医药发展和科教科,上海200540 [3]中国医学科学院血液病医院门诊办公室,天津300020 [4]深圳市龙岗中心医院院长办公室,广东深圳518038

出　　处：《中国卫生产业》2022年第21期253-256,共4页China Health Industry

基　　金：2021年度上海市金山区卫生健康专项科研课题(JSKJ-KTYlT-2021-01)。

摘　　要：为建立一套科学、长效、持续、可推广的糖尿病足闭环防治管理模式,基于国家放射与治疗临床医学研究中心中山糖尿病足多学科诊疗中心、国家放射与治疗临床医学研究中心中山糖尿病足多学科诊疗中心金山运行中心的工作基础,以复旦大学附属中山医院优势学科和先进的医疗技术为支撑,以复旦大学附属金山医院品牌、特色专科以及多学科医疗中心为轴心力量,以社区健康管理、筛查为基础,共同构建“原发病管理—足部管理—血管重建”的多学科综合诊疗管理体系,提出在区域医联体视角下构建“三全”糖尿病足闭环防治管理模式的研究设想。该模式在2021年1—12月运行期间,实现了糖尿病足筛查工作并轨社区卫生服务中心的糖尿病目标人群健康体检,完成首批3146名社区糖尿病建卡人员的糖尿病足筛查,糖尿病足风险占比约23.6%,接受90名来自基层医疗机构的医务人员进修学习,该模式也获得了第四届“上海医改十大创新举措”。在做好糖尿病足患者的血管重建和保肢等治疗的同时,实现了社区糖尿病患者的健康管理、早期筛查和干预。To establish a scientific,long-lasting,sustainable and scalable closed-loop diabetic foot prevention and management model,based on the work of the National Center for Clinical Medical Research in Radiation and Treatment Zhongshan Diabetic Foot Multidisciplinary Treatment Center and the National Center for Clinical Medical Research in Radiation and Treatment Zhongshan Diabetic Foot Multidisciplinary Treatment Center Jinshan Operation Center,supported by the advantageous disciplines and advanced medical technology of Zhongshan Hospital of Fudan University,the brand and specialties of Jinshan Hospital of Fudan University and the multidisciplinary medical center as the axial force,and community health management and screening as the basis,together we build a multidisciplinary integrated diagnosis and treatment management system of"primary disease management-foot management-vascular reconstruction".We propose to build a"three-whole"diabetic foot closed-loop prevention and management model from the perspective of the regional medical association.During the period of operation from January to December 2021,the model realized the screening of diabetic foot and the health examination of diabetic target population in community health service centers,completed the first 3146 diabetic foot screenings for community diabetes builders with approximately 23.6%of diabetic foot risk,accepted 90 medical staff from primary care institutions for further study.This model was also awarded the fourth"Shanghai Medical Reform Top Ten Innovation Initiative".The model was also awarded as one of the"Top Ten Innovative Initiatives of Shanghai Medical Reform"in the fourth session.It has achieved health management,early screening and intervention for diabetic patients in the community,while providing diabetic foot patients with good treatment such as revascularization and limb preservation.

关 键 词：医联体 糖尿病足 防治 闭环管理 

分 类 号：R19[医药卫生—卫生事业管理]