COPD-DMP:the Establishment And Implementation Of The Appropriate Technology For The Prevention And Control Of Chronic Obstructive Pulmonary Disease In The Elderly Of Community In Soochow City

Objective: The latest GOLD–COPD assessment methods for the program,“basicmedical care, basic services, basic equipment” as the starting point, we establish anoperational,“community prevention and control, information management based”COPD-DMP (Disease Management Programmed), to standardize the process ofcommunity services, early intervention in high-risk groups, to seek reasonable chronicdisease prevention and control management system to provide a theoretical and practicalbasis.Methods：1．The establishment of the COPD-DMP community special assessment systemNew concept proposed in2011GOLD-“COPD assessment” as the core, establishcommunity special COPD evaluation system, using the system on the classification of thetarget population of the community COPD group. Evaluation system established, hireexports to assess its reliability and validity. We adjust its content and structure according tothe assessment, and ultimately determine the path and process of COPD-DMP communityspecial evaluation system.2．The establishment of the COPD community prevention and control managementplatformCombine community health service system with the hospital’s medical resources.Community as the platform, we screen COPD high-risk groups and patients according toeducation, free pulmonary function tests and other ways. Based on the screening results,the target population was classified to the community COPD-DMP standardizedmanagement queue.3．The impact assessment of COPD-DMP One year later, we assess the effect. We separately use COPD knowledgequestionnaire, CODP compliance questionnaire, CAT scale to evaluate awareness,compliance and quality of life. Integrate the system, pulmonary function and acuteexacerbation risk to have a composite assessment.Results：1. Successfully establish a community special assessment of COPD.2.There was COPD high-risk people166,patients337,the average age was (70.98士7.39),352men and15women, M: F=2.33:1.3. One year after the implementation, the awareness of high-risk factors, complication anddiagnostic standard have separately increased19.9%,27.3%and29.2%.The compliance ofsmoking cessation, reasonable exercise and proper medication have separately increased28.2%,58.1%and22.6%.Acute exacerbation cases of2times above have reduced to23.9%.The number of Group A has increased15.5%, the number of Group B, C, D havereduced6.9%,5.2%and3.2%.Conclusions： Based on the research and development of COPD-DMP specialassessment system, an elderly COPD comprehensive prevention and control system, whichis practical, prevention and control as starting points, community health services andtertiary hospitals combined, has been successfully constructed. This study provides atheoretical and practical basis for the province and the country.