【作者】 柴云；

【导师】 卢祖洵；

【作者基本信息】 华中科技大学 ， 社会医学与卫生事业管理， 2010， 博士

【摘要】 研究目的慢性非传染性疾病具有发病率高、致残率高和和死亡率高的特点。随着经济的发展,人们生活水平的提高,慢性病人出现日益增多的趋势。2005年中国居民营养与健康状况调查报告表明,我国成年高血压患病人数已超过1.6亿人。慢性病给国家、社会、家庭和个人带来了沉重的疾病经济负担,亟待探究价格低廉、效果好的慢性病管理模式。本研究通过全面系统了解成都市高血压糖尿病患者社区卫生服务利用情况、疾病控制情况、慢性病管理运行情况,总结经验,发现问题,为进一步完善慢性病管理模式提供依据。研究方法本课题主要采用文献研究、现场调查、深入访谈、比较研究方法对成都市社区慢性病管理进行了调查分析。采用文献研究法总结出成都市社区慢性病管理特色,采用描述性分析法分析了高血压糖尿病患者社区卫生服务利用情况、控制情况、知信行情况；采用卡方检验和logistic多元回归分析法分析了患者利用和疾病控制的影响因素；采用主成分分析法和聚类分析法评价了高血压糖尿病患者对社区卫生服务的满意度。研究结果本课题研究结果主要包括以下几个方面：1.成都市社区慢性病建立档案率、规范管理率和管理模式。2006年成都市社区高血压糖尿病患者建档率28.57%,某区的高血压、糖尿病患者规范管理率55.03%、54.22%。成都市形成了分级管理和契约式管理相结合的慢性病管理模式。2.成都市社区高血压糖尿病的疾病控制,利用情况。①人口学特征：调查对象2028人,高血压病人1716例,糖尿病病人590例,既有高血压又有糖尿病的病人278例；其中男性827人(40.5%),女性1207人(59.5%);年龄最大97岁,最小14岁,平均67.10±10.34岁。②利用情况：高血压糖尿病患者利用社区卫生服务监测治疗疾病的比率分别为81.41%、56.95%,监测频率分为一周,一周至两周,两周至一个月,一个月以上四个层次。高血压、糖尿病患者两周至一月监测的频率最高,分别为44.8%、47.5%,高血压患者需要缩短监测周期。③知晓情况：高血压、糖尿病患者一旦药物治疗需要终身服药的知晓率分别为90.0%、86.9%；血压正常值知晓率为79.4%,血糖正常值知晓率79.2%,但正确知晓率分别为48.9%、35.4%,患糖尿病的症状知晓率50.7%,说明基础知识的健康教育工作有待细致深入。④高血压、糖尿病患者服药依从性：按照医嘱服药的比率分别为94.7%、95.1%,规律服药的比率分别为90.9%、94.2%,依从性较好。⑤行为改变情况：患者在社区监测后,高血压患者控制情绪的比率是78.0%,加强锻炼的是76.7%,生活规律的比率是93.0%；糖尿病患者严格控制饮食的比率是57.1%,运动量增加的比率是62.1%。⑥建立健康档案和随访：在调查的2028例慢性病患者中,1819人明确自己是被社区卫生服务机构建立了健康档案,占89.7%；1829接受了全科医生的随访,占90.2%,随访分为门诊随访、入户随访和集体随访,比率分别为70.7%、27.0%、2.3%。⑦控制情况：高血压患者糖尿病患者的控制率分别为76.2、62.5%。3.高血压糖尿病患者社区卫生服务满意度。满意度各要素评分中,服务态度平均分最高(4.45),技术水平平均分最低(4.00)。2066名就诊者对医疗机构满意度的总体评价中,0.1%的就诊者表示“很不满意”或“不满意”。主成分分析结果表明,有4个主因子；聚类分析结果表明,总体满意度、医疗费用、技术水平、出诊时服务态度为一组,就诊手续、慢性病防治讲解主动性为一组,就诊环境、就诊时服务态度看似可以单独为一组,但是又可以划入就诊手续、慢性病防治讲解主动性这一组。4.高血压糖尿病患者利用社区卫生服务机构影响因素的logistic回归分析。影响高血压患者利用社区卫生服务的主要因素,年龄50-69岁、全部自费、城镇居民医疗保险、知晓免费血压测量点、终身服药的原则、建立了健康档案、接受了定期随访是影响高血压患者利用社区卫生服务的保护因素,不知晓血压正常值是影响高血压患者利用社区卫生服务的危险因素。全部自费、城镇居民医疗保险、终身服药的原则、按照医嘱服药、建立了健康档案、入户随访和门诊随访是影响糖尿病患者利用社区卫生服务的保护因素,不知晓血糖正常值是影响糖尿病患者利用社区卫生服务的危险因素。5.高血压糖尿病控制率影响因素的logistic回归分析。知道血压测量点、知晓慢性病药物治疗需要终身服药、规律服药、加强锻炼、入户随访和门诊随访是高血压控制率的支持因素,个体经营者、城镇职工基本医疗保险、城镇居民基本医疗保险、新型农村合作医疗是高血压控制率的不利因素。一般职员／工人／服务员、按照医嘱服药、严格控制每日进食量是糖尿病控制率的支持因素。6.成都市社区慢性病管理措施的特色。成都市社区慢性病管理组织机构和职责清晰；注重规划、系统层次地制订政策,确定考核指标和体系；责任医生制的契约式管理结合了多种形式的健康教育；形成了一套包含慢性病医务人员的培训、晋升、考核、激励等完整的、系统的社区人力资源发展机制；慢性病信息网络化并建立了一个类似提供者提醒的预警系统；通过科研推动慢性病管理的发展。研究结论社区慢性病管理工作取得了一些成效：1.建立了责任医师制及良好的健康教育大环境；2.随访工作改善了医生与患者的关系；3.以重视预防的意识为先导,各相关政府部门联合行动,慢性病管理工作取得实质性进展；4.分级式管理和契约式管理相结合的模式奠定了注重质量发展的良好基础；5.慢性病管理在社区实现了五位一体的功能。但是存在一些问题,主要是：1.社区卫生服务机构与社会医疗保险机构的结合不太紧密,不能保证足够病源；2.慢性病管理方法和手段上存在不足；3.健康教育不能忽视慢性病防治基础知识；4.全科医生的医疗技术有待提高和出诊服务态度有待改善；5.费用仍然是社区卫生服务机构发展的障碍。政策建议促进社区卫生服务机构与社会医疗保险机构的结合,保障慢性病人的健康权益；完善和增加慢性病管理方法和手段,以促进慢性病患者社区卫生服务利用的持续性、控制的有效性；发展自我管理教育,逐步形成病人自我管理；关注成都市慢性病管理薄弱的人群；要加强全科医生的培训,改善全科医生的服务态度,提高全科医生的技术水平；政府待加强对社区卫生服务机构的投入,特别是公共卫生。研究创新1.本研究首次在社区慢性病管理条件下,研究糖尿病患者利用社区卫生服务监测治疗疾病的影响因素。2.本文首次分析了在分级管理和契约式管理相结合的慢性病管理模式形成后的慢性病管理效果。以往的研究局限于小范围的干预。更多还原

【Abstract】 ObjectiveThe chronic disease have three features of high morbidity rate, high disability rate, high mortality rate. Along with the development of economic and people’s living level, chronic patients increased more and more. In 2005 the investigation report of Chinese residents’nourishment and health condition expressed that our country had more than 1.6 hundred million adult hypertension patients. The chronic disease bring heavy disease economy burden to the nation, society, family and the individual, it is urgent to explore cheap and efficient chronic disease management model.To know health service utilization and managemnet of hypertension patients and diabetes millilus in Community Health Centres (CHCs) in ChengDu, and the control condition of the hypertension and diabetes, this research provided basis for related departments to perfect the model of Chronic Disease Management(CDM) by summarizing the experience and discovering problems.MethodsBy combining quantity with quality analyses, this study evaluated the implementation of the model of Chronic Disease Management (CDM) in CHCs in ChengDu. In this study, document analysis, field observation, depth interview, case example research, and comparison research were performed to investigate and analyze the model of CDM in ChengDu. In details, the model and management measures of hypertension patients and diabetes millilus in CHCs were analyzed by document analysis. The utilization rate of hypertension patients and diabetes millilus in CHCs, the control rate of hypertension and diabetes, the awareness, attitude and behavior change rate were analyzed by the descriptive method. The influencing factors were analyzed by chi-square test or unconditional logistic multiple regression analysis. Factor analysis and hierarchical cluster analysis were adopted to study the satisfaction of hypertension patients and diabetes millilus to CHS.ResultsThe results of this study include following:1. The rate of filing health records, standardized-management and the model of CDM in CHCs. In 2006 the rate of filing health records of chronic patients, which include hypertension patients and diabetes millilus, was 28.57%. The rate of standardized-management of high blood pressure, diabetes patients of some area was 55.03% and 54.22%, respectively. In ChengDu the CDM model, which combined management in grades with contractual management, have taken shape.2. The statue of disease control and utilization of CHCs of the hypertension patients and diabetes millilus.①The demographic and sociology characteristic. There were 2028 patients were investigated. Among them,1716 persons are hypertension patients.590 persons are diabetes millilus.278 persons are the hypertension and diabetes patients.821 persons,40.5% are male.1207 persons,59.5% are female. The oldest was 97 years old and the youngest was 14 years old. Average age was 67.10±10.34 years old.②The utilization statue of CHCs:Most hypertension patients and diabetes millilus monitored and treated the disease in CHCs, The rates were 81.41% and 56.95%, respectively. The utilization frequency include four levels:in a week, more than one week in two weeks, more than two weeks in a month, more than a month. More than two weeks in a month was the tallest frequency for both hypertension patients and diabetes millilus. The rates were 44.8% and 47.5%, respectively. It was necessary to shorten the period of monitoring disease for hypertension patients.③The awareness statue of CHCs:The awareness rate of having to take medicine all life once accept medicine treatment of hypertension patients and diabetes patients were 90.0% and 86.9%, respectively. The awareness rate of normal blood pressure and normal blood sugar were 79.4% and 79.2%, respectively. The rates of knowing the right ones were 48.9% and 35.4%, respectively. The all symptoms of diabetes were known by 299(50.7%). It is necessary to strengthen explaining foundational prevention knowledge to the patients.④The rate of complying with General Practitioner(GP)’s advice to take medicine. The rate of complying with GP’s advice to take medicine of hypertension patients and diabetes millilus were high,94.7% and 95.1%, respectively. The ones of regularly complying with GP’s were 90.9% and 94.2%, respectively.⑤The statue of behavior changes: after being monitored and treated in CHCs, the rate of getting less angry, doing more exercises and living more regularly were 78.0%,76.7% and 93.0%, respectively. The rate of dieting strictly and doing more exercises were 57.1% and 62.1%, respectively.⑥Filing health records and follow-up:There were 1819 persons,89.7% knew their health records was filed.1829 persons,90.2% were followed up by GP. Follow-up in clinic or through telephone, door-to-door follow-up and follow-up in meeting with all residents were three kinds of methods of follow-up. The proportions were 70.7%, 27.0% and 2.3%, respectively.⑦The control rate:The control rate of hypertension and diabetes were 76.3% and 62.5%, respectively.3. Health service satisfaction of CDM. Among the factors, the average score of the satisfaction of service attitude was the highest (4.45), and that of the average doctors’technology level was the lowest (4.00). In overall evaluation of the satisfaction to medical organizations,0.1% of the 2006 patients were "very dissatisfied" or "not too satisfied". Main factor analysis indicated that the 7 factors was reduced to 4. Following hierarchical cluster analysis indicated that the total satisfaction of service, expenses, doctors’ technology level, service attitude of visiting patients at home were a set. Procedure of Medical treatment, service attitude of interpreting prevention knowlegde of chronic disease were a set. Medical treatment enviornment, service attitude of seeing a doctor were a set. The later tow sets were merged, and then merged the first set to one set.4. Logistic regression analysis on influencing factors of the CHCs utilization of hypertension patients or diabetes millilus. Age (from 50-year to 69-year), self payment, joining in the Urban Resident. Basic Medical Insurance, awareness of the free charge site of measuring blood pressure, awareness of having to take medicine all life once accept medicine treatment, filing health records and follow-up were protection factors influencing the CHCs utilization of hypertension patients. Not knowing the normal blood pressure was a dangerous factor. Self-payment, joining in the Urban Resident Basic Medical Insurance Scheme, awareness of having to take medicine all life once accept medicine treatment, complying with GP’s advice to take medicine, filing health records, follow-up in clinic or through telephone, door-to-door follow-up were protection factors influencing the CHCs utilization of diabetes millilus. Not knowing the normal blood sugar is a dangerous factor.5. Logistic regression analysis on influencing factors of the control rate of hypertension or diabetes. Awareness of the free charge site of measuring blood pressure, awareness of having to take medicine all life once accept medicine treatment, complying with GP’s advice to take medicine regularly, strengthening physical exercises, follow-up in clinic or through telephone, door-to-door follow-up were protection factors influencing the control rate of hypertension. Self-employed, joining in the Urban Employee Basic Medical Insurance Scheme, joining in the Urban Resident Basic Medical Insurance Scheme, joining the New Rural Cooperative Medical Scheme were dangerous factors. The employee/worker/attendant, complying with GP’s advice to take medicine, strict control of diet were protection factors influencing the control rate of diabetes.6. The measure’s features of CDM in CHS in ChengdDu city. The organization of CDM had and its clear-cut job responsibility. The government payed attention to the long-term programme, establishing the policy systematic and in gradation and setting up a check-on index system to cadres and others in CHCs. The contractual management model of the duty doctor’s system combined with various forms of health education. A complete and systematic development mechanism of community human resources have been posed, including training, rising in rank, check-on, encourages and so on. Chronic disease information was network and established a early-warning system which was similar to provider reminders. The related research pushed the development of CDM.ConclusionsThere are some achievements in CDM in CHCs:The GPs’duty system and good health education environment have been established; Follow-up enhance the relationship between the GPs and the patients; tangible headway was achieved by Consciousness of emphasizing prevention firstly and relevant departments of government cooperating each other; Foundation of laying stress on quality was well established; CDM in community realized five functions of integral wholesed. There are some problems:Relationship between CHCs and social medical insurance institution wasn’t closely enough; We still lacked of methods and measures of CDM; Education of prevention and cure knowledge of chronic disease was not deeply and painstakingly; GPs’medical treatment technique and service attitude of visiting a patient at home should be improved; High medical expenses is still a problem to hypertension patients and diabetes patients in CHS.Policy Suggestions1. We should combine CHCs with social medical insurance institution closely to safeguard chronic patients’health right; 2. We should increase the methods and measures of CDM to increase the utilization level of CHS continuously and improve the control of chronic disease more effectively; 3. Self-management education should be developed to realize patients self manage their disease; 4. There were some persons who should be paid more attention to; 5. We should enhance training GPs to improve their technique level and their service attitude; 6. Government should invest more to CHCs to develop public hygiene service.Innovation1. It is the first time to study the statue of diabetes patients monitoring and treating disease in CHCs and its influencing factors. 2. We firstly evaluated the performance of the CDM management model, which combined management in grades with contractual management.更多还原