Research On Three-grade Management System Of Chronic Kidney Disease

Background: At present,chronic kidney disease(Chronic kidney,disease,CKD)has become a serious threat to human health.CKD has the features of high prevalence rate,low awareness rate,low rate of early diagnosis,poor prognosis,high medical costs and easy to merge cardiovascular and cerebrovascular diseases.Early detection,diagnosis and treatment of CKD,prevention and treatment of various reversible factors and delay progression of kidney disease,have become the problem the masses of the people,clinical medical workers must face.With the prevalence of CKD increased year by year,the demand for medical services increasingly,and the majority of patients with CKD are more likely to visit in the major hospital,resulting in the major hospital "overcrowded",with "difficult to see a doctor",so a reasonable guide CKD patients,reduce the hospital medical load,at the same time to solve the difficult problem of the patients is imminent.However,what affect the patients with CKD to choose hospital is not clear,how to guide the patients reasonable treatment is still unknown.In addition,in the country have carried out three-grade level management,this management model whether suitable for CKD patients,help to delay the deterioration of renal function or not is unknown.So with the help of Beijing Municipal Science and technology funding,we carried out the treatment status of patients with CKD,a preliminary study on the influence factors and three-grade level management linkage system,in order to provide a basis for rational management of patients with CKD.Objective:(1)Acquaintance the status of seeking medical advice of CKD patients;(2)Analysis the factors of selecting the hospital of CKD patients;(3)Observe the feasibility and significance of implementing the three-grade management linkage system.Methods: A multicenter,cluster grouping,prospective,comparative study.In tertiary hospital such as Beijing Tongren Hospital,Peking University People’s Hospital,Beijing Friendship Hospital,Guang’anmen Traditional Chinese Medicine Hospital,district centre hospital such as Beijing Luhe hospital,Beijing Puren Hospital and one community hospital which is the Fangzhuang community hospital,we choose 329 patients with CKD in their outpatients or wards from November 2013 to April 2015 year.Through the questionnaire survey to understand the situation and reason of the patients choose hospitals.According to the cluster grouping,the patients can be divided into the management group(Beijing Tongren Hospital,Beijing Puren Hospital,Beijing Fangzhuang community hospital),which has 206 patients,and control group(Peking University People’s Hospital,Beijing Friendship Hospital,Beijing Guang’anmen Traditional Chinese Medicine Hospital,Beijing Luhe hospital),which has 123 patients.By recording the patients’ general situation and the results of auxiliary examination,we can get the assessment the glomerular filtration rate(estimated,glomerular filtration rate,eGFR)and the staging of the patients.The patients in the management group will be managed by the CKD stage.The patients in the control group will choose the hospital freely.Through this study,we establishment the three-grade management linkage system and the referral green channel.We will record their blood routine,biochemical routine,urine routine,urine protein,glycosylated hemoglobin,eGFR and end point events in 3 months,6 months,12 months,18 months and 24 months.With these data,we will analyse the patients’ condition and the factors which can influence them to choose hospital.After we observe this system in the 24 months,we will estimate the enforceable of this system.Results:1.The status of seeking medical advice of CKD patients: 78.4% CKD patients choose tertiary hospitals or district centre hospitals.The main purposes of choosing tertiary hospitals or district centre hospitals are diagnosis and treatment(85.0%),the others is taking medicine(15.0%).The reason for choosing tertiary hospitals or district centre hospitals is the high level of health care.The main purpose of choosing community hospitals is taking medicine(90.0%).The main reason is convenient.2.Influencing factors: gender,age,family income,medical expenses and the severity of the disease have effects on choosing hospitals,<65 years old,male.Low income(<3000 yuan),non medicare and above 3 stage of chronic kidney disease tend to tertiary hospitals or district centre hospitals(P<0.05).3.The implement of the three-grade management linkage system: when patients were enrolled in management group or control group,the blood glucose,triglyceride(Triacyl glyceride,TG),low density lipoprotein cholesterol(Low Density Lipoprotein Cholesterin,LDL-C),blood uric acid(Urine Acid,UA and eGFR)had no significant difference(P>0.05).After 24 months,the blood glucose,LDL-C,UA and eGFR of stage CKD3-5 have a significant difference between two groups(P<0.05),showed the management group’s blood glucose,LDL-C and serum UA were significantly improved(P <0.05),the level of eGFR of CKD3-5 did not reduced.The control group’ blood glucose,LDL-C,serum UA were significantly higher than before(P <0.05).The level of eGFR of CKD3-5 is decreased,the difference was statistically significant(P<0.05).The results indicated that it is feasible and necessary to implement the three-grade management linkage system.4.End point events: After 24 months of follow-up,there are 68 people in the end point events,occupy 20.7 percentage of the total number of participants.There are 22 people dead(occupy 6.7 percentage of the total number of participants),the main causes of death were pulmonary infection,heart failure,myocardial infarction,malignant tumor.There are 14 people enter dialysis(occupy 4.3 percentage of the total number of participants)and 32 people hospitalized(occupy 9.7 percentage of the total number of participants),the main causes of hospitalization were high blood pressure,diabetes,heart failure,arrhythmia,infection,primary disease progression.The patients were treated in three hospitals and selected three hospitals to further consultation.This indicate that three hospitals are responsible for critically illness.Conclusion: 1.Most CKD patients choose tertiary hospitals or district centre hospitals.2.Gender,age,family income,medical expenses and the severity of the disease are the influencing factors of CKD patients choosing hospitals.3.Implementing the three-grade management linkage system in CKD patients contributes the management of chronic kidney disease,delaying the kidney disease progress and improving the prognosis.4.Three hospitals are responsible for critically illness.