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目的总结高血压、糖尿病病例管理为核心的慢性非传染性疾病防治经验,探索和完善银川市农村慢性非传染性疾病综合防治的有效机制。方法利用工作报表,收集分析2009和2010年工作进展数据;采用试卷对集中培训的卫生院、村卫生工作人员进行了现场培训效果的测试;设计专门问卷,对35名工作人员实际技能掌握、应用情况和228名高血压、98名糖尿病病例管理效果和满意度进行了回顾性调查、分析。结果通过病例管理培训,卫生院有86.96%的工作人员、卫生室有75.00%的工作人员的工作技能得以巩固、掌握(χ2=16.99,P值0.005<0.05),并在实际工作中得到充分的应用;通过对47.30%人口开展筛查,有4549名高血压病例和475名糖尿病病例得到系统管理,管理率为65.43%和69.24%;经系统管理后,高血压转诊住院的仅为管理人数的2.29%,因病住院率为0.12%,糖尿病转诊住院的仅为管理人数的4.00%,因病住院率为0.02%。结论通过引进项目支持,试点地区从无到有,基本建立起以病例管理为核心的新型农村慢性病综合防治机制,此机制具有向全区积极推广的价值。
Objective To summarize the prevention and treatment of chronic non-communicable diseases with hypertension and diabetes management as the core and to explore and improve the effective mechanism of comprehensive prevention and treatment of chronic non-communicable diseases in rural areas of Yinchuan. Methods The work report was used to collect and analyze the data of work progress in 2009 and 2010. The papers were used to test the effect of on-the-spot training for centralized training hospitals and village health workers. The special questionnaire was designed to grasp the practical skills of 35 staff members. Case and 228 hypertension, 98 cases of diabetes management and satisfaction were retrospectively investigated and analyzed. Results Through the case management training, 86.96% of the staff in the hospital and 75.00% of the staff in the clinic were able to consolidate and master the work skills (χ2 = 16.99, P <0.005), and got sufficient Application; by screening 47.30% of the population, 4,549 cases of hypertension and 475 cases of diabetes were systematically administered with a management rate of 65.43% and 69.24%; after systematic management, the number of hypertensive inpatients was managed only 2.29%, the hospitalization rate was 0.12%, and the number of hospital visits for diabetes was 4.00%. The hospitalization rate was 0.02%. Conclusion Through the introduction of project support and pilot areas from scratch, a new comprehensive prevention and treatment mechanism for rural chronic diseases with case management as the core has been basically established. This mechanism has the value of being actively promoted in the whole region.