高血压慢病管理路径的设计与应用

发布时间：2018-05-01 18:02

本文选题：高血压 + 慢病管理路径　；参考：《浙江大学》2017年硕士论文

【摘要】：慢病属于病程长且通常情况下发病缓慢的疾病,发病率和患病人数逐年上升,提升慢病的治疗率和控制率迫在眉睫。慢病管理是慢性病防治的主要手段,目标是通过组织专业医护人员,为慢病患者提供全面、连续、主动的管理。当前,院外患者慢病管理的主要方式是以慢病管理指南为指导,对患者进行面对面或远程干预;在国外,以Chronic Care Model(CCM)为代表的慢病管理模型得到广泛应用。然而,以指南或模型为指导的慢病管理模式未对慢病管理执行过程进行定义,导致慢病管理在不同医疗机构的执行和推广效果参差不齐,管理效能普遍低下。可见,慢病管理需要一种明确可执行的、具有准确时间要求的程序化、标准化的管理路径进行指导。本论文以提高院外慢病管理服务质量为目标,对慢病管理路径进行了设计和应用。论文首先对慢病管理路径设计思路进行了提炼和总结,并以高血压为例,对慢病管理路径进行了定义;以此为基础,设计并开发了高血压慢病管理医生工作平台,辅助医生执行管理路径;最后,论文对高血压慢病管理路径进行了临床应用评估。工作结果如下:●提炼总结了慢病管理路径的设计思路,针对高血压,基于循证医学证据完成了慢病管理路径设计,明确规定了医生对高血压患者的管理流程。●以高血压慢病管理路径为指导设计开发了高血压慢病管理医生工作平台,旨在辅助医生更好地执行慢病管理路径,具有健康数据可视化、随访信息录入、患者分级评估显示等功能模块。●对高血压慢病管理路径进行了临床应用评估,结果表明,所建立的管理路径能够提高医生的工作效率,同时有效提升高血压的治疗率和控制率。本论文提出的高血压慢病管理路径为医生管理高血压患者提供指导,规范了医生的医疗服务行为,进而提升了高血压的治疗率和控制率,同时也为实现其他慢性疾病的规范化管理提供了参考。
[Abstract]:Chronic disease is a kind of disease with long course and slow onset. The incidence and the number of patients increase year by year, so it is urgent to improve the rate of treatment and control of chronic disease. Chronic disease management is the main means to prevent and cure chronic diseases. The goal is to provide comprehensive, continuous and active management for patients with chronic diseases by organizing professional medical staff. At present, the main way of management of chronic disease outside hospital is to conduct face-to-face or remote intervention under the guidance of management guide of chronic disease, and abroad, the model of chronic disease management, represented by Chronic Care Model, has been widely used. However, the slow disease management model guided by guidelines or models does not define the implementation process of chronic disease management, which leads to uneven implementation and promotion of chronic disease management in different medical institutions, and the management effectiveness is generally low. It can be seen that chronic disease management needs a clear executable, with accurate time requirements of the program, standardized management path to guide. The aim of this paper is to improve the service quality of chronic disease management outside hospital, and design and apply the path of chronic disease management. Firstly, the paper abstracts and summarizes the design ideas of slow disease management path, and defines the slow disease management path by taking hypertension as an example, and then designs and develops a doctor's working platform for hypertension chronic disease management. Finally, the paper evaluates the clinical application of the management pathway of chronic hypertension. The results are as follows: the design idea of chronic disease management path is summarized. Aiming at hypertension, the design of chronic disease management path is completed based on evidence of evidence-based medicine. The management process of hypertension patients is clearly stipulated. The working platform of doctors for managing hypertension chronic diseases is designed and developed under the guidance of the management path of chronic hypertension disease, which aims to assist doctors to implement the management path of chronic diseases better. Health data visualization, follow-up information input, patient grading evaluation and other functional modules. The clinical application evaluation of hypertension slow disease management pathway, the results show that the established management path can improve the work efficiency of doctors. At the same time, improve the treatment rate and control rate of hypertension. The management path proposed in this paper provides guidance for doctors to manage patients with hypertension, standardizes doctors' medical service behavior, and then improves the rate of treatment and control of hypertension. At the same time, it also provides a reference for the standardized management of other chronic diseases.
【学位授予单位】：浙江大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：TP311.52;R544.1

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