摘要
目的探索和实践信息化基础的社区卫生服务机构-疾病预防控制中心-综合医疗机构的"三位一体"的慢性病综合管理模式。方法回顾性总结和分析2007—2010年全区社区卫生服务中心、二级以上综合医疗机构、区疾病预防控制中心,应用信息化基础的慢性病"三位一体"管理模式对高血压、糖尿病、常见肿瘤等的管理情况。结果应用信息化基础的慢性病"三位一体"管理模式后,慢性病的管理数量明显增长,随访方式转变为临床预防的充分结合,心脑血管疾病的发病率降低,糖尿病前期、糖尿病和常见肿瘤的早发现率提高。结论倡导信息化基础的慢性病"三位一体"综合管理模式,有助于形成慢性病预防-诊治-康复无缝隙的全程干预和有针对性的人群分类管理,实现慢性病早发现,降低远期发病率,减少并发症。
Objective To evaluate the information -based ＂ Community Health Service -Center for Disease Control and Prevention - General Hospital＂ management model of chronic diseases. Methods The information - based Trinitarian man- agement mode for chronic diseases including hypertension, diabetes, and common tumors during 2007 and 2010 was analyzed retrospectively. Results After the application of the Trinitarian management mode, the coverage of chronic disease management remarkably increased, the follow - up effectively combined the treatment and prevention, the incidences of cardiovascular and ee- rebrovascular diseases were effectively lowered, and the early detection rate of pre - diabetes, diabetes and common tumors were elevated. Conclusion Information - based Trinitarian management model may help establish a classified and seamless process of prevention - treatment - rehabilitation of chronic diseases, which in turn, may lead to early detection and effective management of chronic diseases.
出处
《中国全科医学》
CAS
CSCD
北大核心
2012年第7期729-732,共4页
Chinese General Practice
关键词
慢性病
管理模式
信息化
社区卫生服务
Chronic diseases
Management model
Informatization
Community health services
