以三级综合医院为主导的“1+N”CKD联动管理模式的建立与评价  

Establishment and Evaluation of“1+N”Linkage Management Mode of ChronicKidney Dis⁃ease Led by Tertiary General Hospitals

作　　者：邹芸[1] 狄佳[1] 赵诗竹 周华[1] 杨艳[1] 刘华[1] 杨敏[2] ZOU Yun;DI Jia;ZHAO Shizhu;ZHOU Hua;YANG Yan;LIU Hua;YANG Min(Department of Nephrology,The first People’s Hospital of Changzhou,Changzhou,Jiangsu,213003;Medical Department,The first People’s Hospital of Changzhou,Changzhou,Jiangsu,213003)

机构地区：[1]常州市第一人民医院肾内科,江苏常州213003 [2]常州市第一人民医院医务处,江苏常州213003

出　　处：《江苏卫生事业管理》2023年第6期730-734,共5页Jiangsu Health System Management

基　　金：常州市科学技术局支撑(社会发展)项目(CE20215024)。

摘　　要：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 generalhos⁃pital,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 statistical⁃ly.Results:After the implementation of the“1+N”linkage management,the number of initial diagnosis,up-referral patients,down-re⁃ferral 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 diagno⁃sis and treatment process,is conducive to promoting the formation of the medical order of“first diagnosis at the grass-roots level,twoway referral,emergency and slow treatment,and linkage between the upper and lower levels”.

关 键 词：慢性肾脏病 联动管理 分级诊疗 

分 类 号：R197.3[医药卫生—卫生事业管理]