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糖尿病足多学科分级闭环管理体系的构建

Construction of multi-disciplinary hierarchical closed-loop diabetic foot management system

  • 摘要: 随着我国人群糖尿病患病率的提高,糖尿病足患病率逐年上升,2021年我国糖尿病足患者数以百万计。目前糖尿病足防治存在以下难题:诊断延迟;涉及多个科室,难以协同治疗;随访和监控困难;缺乏高危人群的筛查和宣教。为解决上述难题,在MDT模式的基础上应逐步建立“糖尿病足多学科分级闭环管理体系”,有望为糖尿病足确诊或高危患者提供专业、精准、系统、个体、全方位的“一体化”疾病管理模式。该体系包括横向“多学科诊疗”和纵向“闭环分级管理”,体系运作注重防治结合,预防上兼顾重点人群随访、高危人群筛查以及全人群科普宣教,治疗上做好一线工作者基础知识培训、对治疗模式与时机把控达成共识、打通多向转诊通道。通过这一体系的建立,逐步做到糖尿病足的“应知尽知”、“应防尽防”、“应治尽治”,形成糖尿病足多学科分级闭环管理体系的建设标准,逐步在上海市、长三角、乃至全国推广,推动我国糖尿病足诊疗工作不断进步。

     

    Abstract: With the increase of the prevalence of diabetes in China, the prevalence of diabetes foot is also increasing. In 2021, there are millions of diabetic foot patients in China. At present, the problems of the prevention and treatment of diabetic foot are as follow: delayed diagnosis; multiple departments involved but unable to cooperate; difficulty in follow-up and monitoring; lack of screening and education for high-risk population. In order to solve these problems, we should gradually establish a "multi-disciplinary hierarchical closed-loop management system for diabetic foot" based on the MDT model, which is expected to provide a professional, accurate, systematic, individual, comprehensive and integrated disease management model for diabetic foot patients who have been already diagnosed or at high risk. The system includes horizontal "multi-disciplinary diagnosis and treatment" and vertical "closed-loop hierarchical management". The system focuses on the combination of prevention and treatment. Prevention takes into account the follow-up of key groups, screening of high-risk groups and popular science education of the whole population. In treatment, the basic knowledge training of front-line medical staff is required, consensus on the treatment mode and timing should be reached, and the multidirectional referral channel must be unblocked. Through the establishment of this system, we will gradually achieve the goal of "knowing as much as we should", "preventing as much as we could", and "treating as much as we must" of diabetic foot, form the standard of a multi-disciplinary hierarchical closed-loop management system for diabetic foot, and gradually promote the model in Shanghai, in the Yangtze River Delta, and even the whole country, so as to promote the continuous progress of diabetic foot diagnosis and treatment in our country.

     

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