本文選題：高血壓 + 慢病管理路徑��； 參考：《浙江大學》2017年碩士論文

【摘要】：慢病屬于病程長且通常情況下發(fā)病緩慢的疾病,發(fā)病率和患病人數(shù)逐年上升,提升慢病的治療率和控制率迫在眉睫。慢病管理是慢性病防治的主要手段,目標是通過組織專業(yè)醫(yī)護人員,為慢病患者提供全面、連續(xù)、主動的管理。當前,院外患者慢病管理的主要方式是以慢病管理指南為指導(dǎo),對患者進行面對面或遠程干預(yù);在國外,以Chronic Care Model(CCM)為代表的慢病管理模型得到廣泛應(yīng)用。然而,以指南或模型為指導(dǎo)的慢病管理模式未對慢病管理執(zhí)行過程進行定義,導(dǎo)致慢病管理在不同醫(yī)療機構(gòu)的執(zhí)行和推廣效果參差不齊,管理效能普遍低下�？梢�,慢病管理需要一種明確可執(zhí)行的、具有準確時間要求的程序化、標準化的管理路徑進行指導(dǎo)。本論文以提高院外慢病管理服務(wù)質(zhì)量為目標,對慢病管理路徑進行了設(shè)計和應(yīng)用。論文首先對慢病管理路徑設(shè)計思路進行了提煉和總結(jié),并以高血壓為例,對慢病管理路徑進行了定義;以此為基礎(chǔ),設(shè)計并開發(fā)了高血壓慢病管理醫(yī)生工作平臺,輔助醫(yī)生執(zhí)行管理路徑;最后,論文對高血壓慢病管理路徑進行了臨床應(yīng)用評估。工作結(jié)果如下:●提煉總結(jié)了慢病管理路徑的設(shè)計思路,針對高血壓,基于循證醫(yī)學證據(jù)完成了慢病管理路徑設(shè)計,明確規(guī)定了醫(yī)生對高血壓患者的管理流程。●以高血壓慢病管理路徑為指導(dǎo)設(shè)計開發(fā)了高血壓慢病管理醫(yī)生工作平臺,旨在輔助醫(yī)生更好地執(zhí)行慢病管理路徑,具有健康數(shù)據(jù)可視化、隨訪信息錄入、患者分級評估顯示等功能模塊。●對高血壓慢病管理路徑進行了臨床應(yīng)用評估,結(jié)果表明,所建立的管理路徑能夠提高醫(yī)生的工作效率,同時有效提升高血壓的治療率和控制率。本論文提出的高血壓慢病管理路徑為醫(yī)生管理高血壓患者提供指導(dǎo),規(guī)范了醫(yī)生的醫(yī)療服務(wù)行為,進而提升了高血壓的治療率和控制率,同時也為實現(xiàn)其他慢性疾病的規(guī)范化管理提供了參考。
[Abstract]:Chronic disease is a kind of disease with long course and slow onset. The incidence and the number of patients increase year by year, so it is urgent to improve the rate of treatment and control of chronic disease. Chronic disease management is the main means to prevent and cure chronic diseases. The goal is to provide comprehensive, continuous and active management for patients with chronic diseases by organizing professional medical staff. At present, the main way of management of chronic disease outside hospital is to conduct face-to-face or remote intervention under the guidance of management guide of chronic disease, and abroad, the model of chronic disease management, represented by Chronic Care Model, has been widely used. However, the slow disease management model guided by guidelines or models does not define the implementation process of chronic disease management, which leads to uneven implementation and promotion of chronic disease management in different medical institutions, and the management effectiveness is generally low. It can be seen that chronic disease management needs a clear executable, with accurate time requirements of the program, standardized management path to guide. The aim of this paper is to improve the service quality of chronic disease management outside hospital, and design and apply the path of chronic disease management. Firstly, the paper abstracts and summarizes the design ideas of slow disease management path, and defines the slow disease management path by taking hypertension as an example, and then designs and develops a doctor's working platform for hypertension chronic disease management. Finally, the paper evaluates the clinical application of the management pathway of chronic hypertension. The results are as follows: the design idea of chronic disease management path is summarized. Aiming at hypertension, the design of chronic disease management path is completed based on evidence of evidence-based medicine. The management process of hypertension patients is clearly stipulated. The working platform of doctors for managing hypertension chronic diseases is designed and developed under the guidance of the management path of chronic hypertension disease, which aims to assist doctors to implement the management path of chronic diseases better. Health data visualization, follow-up information input, patient grading evaluation and other functional modules. The clinical application evaluation of hypertension slow disease management pathway, the results show that the established management path can improve the work efficiency of doctors. At the same time, improve the treatment rate and control rate of hypertension. The management path proposed in this paper provides guidance for doctors to manage patients with hypertension, standardizes doctors' medical service behavior, and then improves the rate of treatment and control of hypertension. At the same time, it also provides a reference for the standardized management of other chronic diseases.
【學位授予單位】：浙江大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：TP311.52;R544.1

【參考文獻】

相關(guān)期刊論文 前7條

1 王鴻懿;孫寧玲;;2014美國成人高血壓管理指南介紹[J];中國醫(yī)學前沿雜志(電子版);2014年01期

2 閆睿;;《2014成人高血壓管理指南》推薦意見[J];中國循證心血管醫(yī)學雜志;2013年06期

3 吳兆蘇;霍勇;王文;趙連友;朱鼎良;;中國高血壓患者教育指南[J];中華高血壓雜志;2013年12期

4 黨愛民;陳炳偉;;2013歐洲高血壓學會/歐洲心臟病學會高血壓管理指南更新要點解讀[J];中國循環(huán)雜志;2013年06期

5 ;家庭血壓監(jiān)測中國專家共識[J];中華高血壓雜志;2012年06期

6 ;中國心血管病預(yù)防指南[J];中華心血管病雜志;2011年01期

7 楊振華;指南與循證醫(yī)學[J];中國循證醫(yī)學雜志;2004年11期

，

本文編號：1830471