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基于社区管理视角的糖尿病足闭环管理模式

The closed-loop management model of diabetic feet based on the perspective of community management

  • 摘要: 糖尿病足(diabetic foot, DF)作为糖尿病患者残疾的主要原因之一,有较高的复发率,对患者家庭及社会造成了沉重的经济负担与压力。DF最常见的临床表现是足部溃疡,它是导致糖尿病患者截肢的重要原因。我国的糖尿病足溃疡(diabetic foot ulcers, DFU)患者具有病情复杂、感染状况严重、预后不良的特点,临床诊治中也存在筛查评估不到位、治疗不规范的问题。本研究基于基层医疗机构的视角,分析DF在社区管理及综合医院资源整合的现况,初步探讨DF患者管理中面临的主要问题,通过实践DF基层首诊、双向转诊及多学科三级闭环管理等管理流程,讨论在基层医疗机构建立针对高危足的主动筛查标准和信息管理平台的可行性,以期通过DF闭环分级诊疗全流程管理的规范路径,探索建立DF一体化闭环诊疗管理的理想模式,为推动落实分级诊疗,提供高质量的社区卫生医疗服务,降低社会和患者家庭疾病负担起到积极作用。

     

    Abstract: Diabetic foot (DF) is a major cause of diabetes-related disability, its high recurrence rate and medical costs produce great economic and social burden to patients and their family. Diabetic foot ulcer (DFU) is the most common clinical manifestation in DF patients and an important cause of amputation in diabetic patients. Chinese patients with DFU generally have the characteristics of complex disease, serious infection and poor prognosis. Meanwhile, there are many problems such as inadequate screening evaluation and non-standard treatment, in clinical diagnosis and treatment. Based on the perspective of primary medical institutions, this study analyzed the current situation of community diabetes management and the integration of general hospital resources, and made a tentative exploration on the main problems of community diabetes management. Through the practice of the process of DF management, from first diagnosis, dual referral to multidisciplinary closed-loop management, this article discusses the feasibility of establishing an active screening standard and information platform for high-risk foot ulcer in basic medical institutions. So far as to explore the establishment of an ideal model of integrated closed-loop diagnosis and treatment management for DF patients through the standardized path of the whole-process management of closed-loop hierarchical diagnosis and treatment. Ultimately it is highly possible that the ideal model of integrated closed-loop diagnosis and treatment management for DF patients would promote the implementation of hierarchical diagnosis and treatment and provide high-quality community health and medical services, at the same time has a positive effect on reducing the burden of the disease on society and DF patients family.

     

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