[在DM77框架内,以数据为导向的方法优化慢性患者的管理]
Maria Teresa Greco1, Pietro Magnoni2, Walter Bergamaschi3
1SC Unità di Epidemiologia, Agenzia di Tutela della Salute Città Metropolitana di Milano, Milano.
Epidemiologia e prevenzione
|June 12, 2025
概括
这项研究确定了意大利60万名符合社区基础慢性病管理资格的患者. 该模型优先考虑需要区域护理的患者,通过综合的全科医生 (GP) 和社区住房服务.
科学领域:
- 公共卫生 公共卫生
- 医疗保健管理的管理
- 慢性疾病流行病学 慢性疾病流行病学
背景情况:
- 稳定的慢性疾病需要在医疗保健系统内制定有效的管理策略.
- 意大利部长法令77/2022授权在社区卫生中心 (CdC) 内部开发区域服务,用于慢性疾病管理.
- 识别和优先考虑符合条件的患者对于成功实施这些新的护理途径至关重要.
研究的目的:
- 开发适合区域服务的工具来识别和优先考虑患有稳定慢性疾病的患者.
- 根据DM77.7,在社区卫生中心 (CdC) 中定义专门护理途径的队列.
- 分析患者特征,包括疾病持续时间和医疗保健利用率,以优化护理规划.
主要方法:
- 使用米兰卫生保护局 (ATS Milano) 的2023年数据进行的回顾性观察研究.
- 分析流行数据,包括住院,急诊室 (ER) 访问和多疗法,以确定慢性疾病.
- 选择标准用于确定符合领土管理条件的队列,考虑疾病持续时间和全科医生 (GP) 访问.
主要成果:
- 在ATS米兰350万居民中,有35%的人至少有一种慢性疾病,其中动脉高血压和高胆固醇血症是最常见的.
- 根据住院治疗,急诊室接入和治疗数据,16种慢性病理被确定为区域援助的优先事项.
- 在2023年,超过6万名被确定为领土管理的患者 (10.2%) 没有进行GP访问,这凸显了初级保健参与的差距.
结论:
- 大约有60万名受试者被确定为有资格获得领土护理,强调了GP和社区房屋服务的整合.
- 拟议的模型有助于在意大利国家卫生系统内规划慢性疾病护理,与DM77指南保持一致.
- 在全国范围内验证和扩展这种方法可以显著改善慢性病的管理和医疗保健资源的分配.
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