| BackgroundIn recent years, with rising medical costs, the inadequate and overly expensive medical services increasingly obtain society and public attention. In 2004, China began to implement system of limited price for single disease, for reducing hospitalization cost price. In order to more accurately, more scientific limite hospital expense, ensure the hospitalization expense benefit, hospital management mode of clinical pathway has been adopted by various hospitals. Clinical pathway can shorten inpatient days, save costs and ensure hospitalization desired therapeutic effect.Chronic renal failure, with long and complex course, often has longer inpatient days, higher hospital expense, and higher readmission rate. Shaping the clinical pathway, to standard hospital management process, short inpatient days, reduce hospitalization fees, has become a top priority.Medical scheme is the core of the clinical pathway. At present, there is no effective drugs delay renal failure. Years of clinical experience show that Chinese medicine has made the obvious effect in some aspects, such as alleviating symptoms of chronic renal failure, protecting residual renal function, slowing progress in mid early renal function, delaying into replacement therapy. Therefore, formulation of chronic renal failure of combining traditional Chinese and western medicine clinical pathway through optimizing of TCM therapy in clinical pathway, will standard hospital management process,fully play TCM special advantage, effectively relieve chronic renal failure.Research purposes1. According to the scientific principle of clinical pathway construction, we optimized the TCM diagnosis scheme of chronic renal failure, and initially formed a TCM therapy with high degree of consensus, sufficient evidence, and powerful generalization, for providing the core content of clinical pathway. 2. With preliminary clinical observation of chronic renal failure clinical pathway, we preliminary discuss clinical effect of chronic renal failure clinical pathway of nondialytic period, through comparison of results of retrospectively analyzed records, to provide basis for further optimization of clinical pathway.Research contentThis research is divided into two parts. The first part of the research focuses optimization of chronic renal failure of nondialytic treatment scheme of TCM. The second part of the research is to carry on the preliminary clinical observation of chronic renal failure combine traditional Chinese and western medicine clinical pathway.1. constructing optimal research of clinical pathway(1) Optimization of chronic renal failure nondialytic treatment scheme of TCMThrough the survey of the chronic renal failure diagnosis and treatment scheme, we summarize the medical situation of chronic renal failure, and extract TCM treatment, which has high degree of consensus, good curative effect, and powerful generalization. And which should do further literature research, because there are differences of TCM diagnosis and treatment.In literature research, we explore Chinese literature from 1999 to 2009, using CBM database and VIP database, and English literature from 2004 to 2009, using pubmed database. By formulating the inclusion and exclusion criteria for literature, filling in registration document, constructing the document database, we analyze and summary the content of literature using content analysis.In expert consultation, we consult the twenty experts advice for diagnosis and treatment with low degree of consensus, no sufficient evidence to support. We form the consulting questionnaire, using written form of counseling. After two rounds of consulting, we form the preliminary diagnosis and treatment scheme and for expert advice by the third round.(2) Formulating clinical pathway based on TCM diagnosis of the optimization schemeWith regard to the retrospective study results, we determine the management time of clinical pathway, and formulate inclusion and exclusion criteria, and then design implementation flow path. According to the clinical pathway issued by health ministry in 2009, we formulate clinical pathway of chronic renal failure of nondialytic period.2. clinical observation research of clinical pathwayWe collect 33 patients with chronic renal failure of clinical pathway form January to March in 2010. then we recorded clinical symptoms, lab indexes, hospital stay, and Hospital expense before implementation and after. Also we included records with path into standard from January 2004 to December 2007, and analysis the record number, hospitalization cost and improved hospital lab index before hospitalization and after. Through the comparison, we discussed the clinical benefits of clinical pathway.Research results1. constructing optimal research of clinical pathway(1) Optimization of chronic renal failure nondialytic treatment scheme of TCM①The survey of the chronic renal failure diagnosis and treatment schemeThe survey of the chronic renal failure diagnosis and treatment scheme Traditional Chinese medicine combined therapy has curative effect, high degree of consensus, and powerful generalization. But it is difficult to unity because varied form. TCM syndrome differentiation and treatment has divergence needing further literature research. In Chinese patent medicine, uremic clearance granule, Chongcao preparation, and haikunshenxijiaonang have high using frequency. In Characteristics of therapy, Traditional enema has curative effect, high degree of consensus. Through analyzing information extraction and frequency analysis, we preliminary summary the basic formula.Therapeutic advantage also reflects in the treatment of chronic complications. Currently, renal anemia, renal malnutrition have certain curative effect. But the point of TCM therapy, pathogenic factor and the application in various forms are not uniform, needing further literature research.②literature research.Traditional Chinese medicine combined therapy, reported in the literature, has two couplet therapy, Sanlian therapy and quad therapy. Among the many therapy, two couplet therapy and sanlian therapy have been frequently used. The two couple therapy mainly includes oral medicine and enema. Sanlian therapy are mainly Chinese medicine + static drops + enema, Oral medicine+enema+skin dialysis, Herbal medicine+enema+topical, Oral medicine+enema+point injection or apply medicine, acupuncture spurs and laser irradiation.TCM diagnosis and treatment of oral liquid form, Specific syndrome type has not unified, needing further studies expert advice.Among chronic complications of chronic renal failure of TCM therapy, currently reported more is renal malnutrition and renal anemia. The TCM treatment principle of renal malnutrition include nourishing kidney, spleen and stomach, invigorating blood, droping turbidity, clearing away heat and eliminating dampness. The TCM treatment principle of renal anemia include filling kidney essence, nourishing liver and spleen, tonifying qi and producing blood, removing stagnation and detoxification. There is treatment for combining traditional Chinese and western medicine treatment, still no Chinese medicine treatment. Also the formula has low degree of consensus.〦xpert consultationIt is suggested using differentiation mixed by deficiency in the origin and excess in the superficiality in chronic renal failure of TCM. The doctors should determine the basic syndrome factor, form basic type certificate, according to the deficiency of the basic.The basic types of syndromes of CKD 3-4 period include the syndrome of deficiency Ben(deficiency of spleen and kidney cured with xiangshaliujunzi soup; deficiency of qi and yin cured with shenqidihuang pill; deficiency syndrome of both liver and kidney yin cured with liuweidihuang soup and erzhi pill; deficiency syndrome of both spleen and kidney yang cured with jishengshenqi pill; deficiency of yang and yin cured with jinkuishenqi pill and erzhi pill), and the syndrome of excessive Biao(dampness syndrome; Dampness-heat syndrome; blood stasis syndrome; water-dampness syndrome; chaotic-toxic syndrome). We treat the syndrome of excessive Biao through increasing and decreasing some traditional herbs according the syndrome of deficiency Ben.The TCM therapy of chronic renal failure complication renal anemia and malnutrition was suggested add herbals on the basis of TCM syndrome differentiation. There are two TCM treatment points of renal malnutrition, one is according to the clinical stages, before the azotemia period. Another is by severe malnutrition, that is light, medium malnutrition. Most experts think hemoglobin in 80 ~ 11 g/L can not use erythropoietin treatment, only TCM syndrome differentiation and treatment.Renal malnourished therapeutic rule mainly adopts nourishing kidney, spleen and stomach, invigorating blood, droping turbidity. The basic formula contains huangqi, dangsheng, baishu, danggui, shudi, shanyurou, huaishan, taizisheng, dansheng, gouqi, xiulinpi. TheTCM treatment principle of renal anemia include filling kidney essence, nourishing liver and spleen, tonifying qi and producing blood, removing stagnation and detoxification. The basic formula contains beiqi, danggui, dangsheng, shudi, heshouwu, tusizi, baishu, gouqi, ajiao, xianlinpi, baishao, ziheche.In the third round of expert advice, eight experts completely agree with the scheme,12 experts basic agree with the scheme in 20 specialists.(2) Formulating clinical pathway based on TCM diagnosis of the optimization scheme2. the clinical observation research of clinical pathwayBefore and after the treatment of clinical pathway, symptoms of patient improved obviously, such as weakness and fatigue, eat less, floating face limb swelling, lumbar debility, mouth dry and bitter, nausea, chills limb cold, abdominal distension, move bowels dry(P<0.05或P<0.01). Compared with the results of medical statistics review, days, western medicine therapy cost, and inspection charges obviously reduced(P<0.05). Kidney and hospitalization expenses improved after the implementation of path. But there were non-significance difference with the retrospectively medical results.Conclusion1. The core of clinical pathway, combining traditional Chinese and western medicine, of Chronic renal failure in nondialytic period is TCM treatment scheme. This research primarily formulates TCM therapy of chronic renal failure in nondialytic period, through investigation of diagnosis and treatment TCM scheme of chronic renal failure nationwide, Literature research, and expert consultation. We preliminary made of TCM therapy of chronic renal failure in nondialytic period, which include traditional Chinese medicine combined therapy, and chronic complications of TCM therapy. Traditional Chinese medicine combined therapy include oral herbal medicine, Chinese patent drug, and traditional enema. We Preliminary determine the TCM syndrome differentiation, basic formula of oral herbal medicine, the basic Chinese medicine of enema, the TCM therapy point of Chronic complications.2. With regard to the retrospective study, we determine target population and the exit criteria of path, total path time limit, implement processes of path on the basis of optimized scheme. Also we form path form, according to path form format issued by the state ministry.3. The clinical pathway regulates the management of our hospital process, shortens hospitalization days, improves patient clinical symptoms; ensure the quality of medical treatment. Althoughthe total hospital expenses dropped, with the rising medical costs were no significant differences compared with statistical results. But the cost of western medicine and examination has obviously decreased with significant differences. Explanation of clinical pathway standardized management and strengthen the characteristics of the application. Renal improvement has no statistically significant differences, before and after treatment of clinical pathway. Further follow-up study is necessary.
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