Build a three -high co -pipe mode to comprehensively improve the health level of chronic diseases

——The person in charge of the Endocrine Team of the Comprehensive Medical Department of Baihuien Hospital of Shanxi Province Guo Jianjin

Hypertension, diabetes, and abnormal blood lipids are the three important risk factors that lead to rising cardiovascular and cerebrovascular disease in my country. In recent years, the endocrine team of the Comprehensive Medical Department of Baihunen Hospital in Shanxi Province has tried it first to actively explore the "three high -common management" chronic disease management model, achieved positive results, and walked at the forefront in the province. A few days ago, this website interviewed Guo Jianjian, deputy director of the comprehensive medical department of Bethune Hospital in Shanxi, on the issue of "three high co -management".

Question: The "three high co -management" of Baihuien Hospital in Shanxi Province is at the forefront of the province. So under what circumstances does your hospital start this slow disease management model?

Answer: The State Council has repeatedly proposed the "Three Gao Communist Party" management thoughts. We thoroughly implemented the relevant instructions of the State Council and explored the management model in combination with many years of clinical experience.

The latest data from the "Report on Nutrition and Chronic Diseases (2020)" released by the State Council News Office shows that the prevalence of hypertension at the age of 18 and above in my country is 27.5%, the prevalence of diabetes is 11.9%, hypercholesteroidsmiamia, and hypertrophymiamia. The prevalence is 8.2%. The patients are huge, and the three highs have individual aggregation. "Healthy China Action (2019-2030)" proposes: Promote the "three high co-tubes" and do a good job of standardized management of blood pressure, blood sugar, and blood lipids. The "Notice of the General Office of the State Council on Deepening the Reform of Deepening the Medical and Health System in 2022" proposes that it is necessary to promote the pilot of "three highs" of hypertension, hyperglycemia, and hyperlipidemia, improve the suitable technical and service model of chronic disease health management, and promote the grassroots level Integration management of chronic pathologists.

It is found in our daily work that diabetic patients have different importance to blood pressure and blood lipids, but the three highs have individual gathering phenomena. Hypertension, hyperglycemia, and hyperlipidemia are the most important risk factor for cardiovascular and cerebrovascular diseases. Objectively, this requires unified management to promote lifestyle intervention, establish a unified, standardized, simple, and easy diagnosis and treatment management process suitable for the grassroots, so as to save medical resources, improve management effects, and delay the occurrence and occurrence of diabetes complications and Progress has inhibited the incidence of cardiovascular and cerebrovascular disease from the source.

Therefore, we must carry out the "three high co -management" without conditions to create conditions. The inflection point of the decline in cardiovascular and cerebrovascular diseases has implemented the goal of national strategy and chronic disease prevention and control of healthy China.

Question: How did Shanxi Baihu En Hospital promote the "three high co -management"?

Answer: On the basis of many years of clinical experience, we have continuously explored and improved the three -disease co -management management model. From April 2021, a basic working model has been formed.

This model is: the care team consisting of a doctor, diabetic educator, nutritionist, and sports instructor, etc., comprehensively use new technical means such as mobile Internet, the Internet of Things, cloud, artificial intelligence, etc. to manage patients to manage patients. The service extends from the hospital to the outside of the courtyard, from offline to online, forming a full -course standardized management closed -loop of the entire hospital integration, offline and online integration, and software and hardware service integration, and the patient -centered service supply is realized.

In the hospital, we will give patients a one -to -one personalized education, inform them of the regular consultation, examination test, screening, and add consultation in a timely manner according to the patient's situation. Outside the hospital, the medical staff will regularly follow the phone to follow the patients, and they will understand the treatment in a timely manner when there are high and low blood sugar alarm. App online attention to patients, let patients have questions, some people ask, some problems are in charge, some health knowledge should be pushed, and the doctor's order is implemented.

Question: What achievements have been achieved since Promoting the "Three High Communities" in Shanxi Baihunen Hospital.

Answer: Since April 2021, we have managed more than 1,900 patients, and the number of patients has continued to rise. It has also achieved certain results for patients who joined our team management.

In terms of medical data, some studies have been conducted for patients who have been managed three months later. Studies have shown that the average value of glycated hemoglobin managed patients has been reduced from 8.5%before management to 6.8%after management; The rate has risen from 27.63%before management to 63.16%; the adverse rate of adverseness has dropped from 35.53%before the management to 7.89%; the average value of empty blood glucose has also dropped from 10.3mmol/L before management to 7.2mmo/L; After meals, the blood sugar dropped from 12.1mmo/L to 9.1mmo/L; the incidence of hypoglycemia also decreased from 1.08%before management to 0.8%, reducing the risk of hypoglycemia. Among the currently managed diabetic patients, 29.5%are merged with hypertension, and 15.5%are combined with hyperlipidemia. In the management of blood lipids, the standard rate of HDL-C has increased from 48%of the baseline to 59%. At 44.6%, the TG's standard rate increased from 45.7%of the baseline to 53.5%. It has also achieved good results in the management of blood pressure, and the standards of blood pressure rose from 28.2%of the baseline to 65.2%.

From the perspective of all aspects of society, the "three high co -management" benefits all parties. For patients, joining the "three high co -management" teams, exported to the hospital, and professional medical staff to remind and guide, and care for them to formulate personalized and standardized full -disease management. Reduced the number of patient clinics. There are also many patients with discontinued drugs in management. The treatment plan for many patients with type 2 diabetes is also from complex to simple. It has gradually excessively excessive injection treatment from insulin to three -combined two -combined treatment, and even single drug control. In this way, the patient's execution and coordination will also be greatly improved; for the hospital, the diagnosis and treatment efficiency of outpatient clinics is improved, more patients are managed, and patient compliance, treatment effect, satisfaction, and long -term stable doctor -patient relationship; For the government, it is even more improving the health of residents, thereby reducing the burden on medical insurance. Question: In the next step, how will Shanxi Bethune Hospital further promote the "three high common management" slow disease management?

Answer: "Three High Co -Tube" is an important way to regulate the management of chronic diseases. This requires summarizing past management experience and combining the personality characteristics of the personality characteristics and characteristics of the local chronic disease patients. Specific management measures for types of patients, control the progress of the disease, prevent the occurrence of complications, and improve the quality of life.

The "three high co -management" began to implement the management of standardized chronic diseases. By establishing a management system, establishing health files, health education, living guidance, follow -up management and other measures to achieve standardized management of patients with chronic diseases Lifetime, obey your medicine, monitor blood pressure, blood lipids, blood sugar, etc., and control the progress of the disease.

Character introduction:

Guo Jianjin, a doctor of medicine, an associate professor, a chief physician, a master's tutor, and deputy director of the General Medical Department of Bethune Hospital in Shanxi. From March 2017 to March 2018, he was selected as a Harvard Alumni Record of Harvard Medical Health Management (Climb-Lead) students. From September 2017 to September 2018, as a visiting scholar at the University of Miami, a basic study of endocrine metabolic diseases. In 2019, he was selected into the American International Medical Education Research Association and was the first member of Shanxi. After returning to China, the main research direction is diabetes and lipid metabolism -related clinical studies. He presided over 2 national projects and 6 provincial scientific and technological projects; in 2014, he won the second prize of scientific and technological progress in Shanxi Province and published 12 SCI papers.

The main academic positions include: Youth Member of the Chinese Medical Association's Endocrine Branch, Standing Committee Member of the Shanxi Provincial Experts and Scholars Association, Deputy Chairman Committee of the Youth Committee of the Youth Committee of the Shanxi Medical Association, Standing Committee member of the Shanxi Provincial Female Physician Association Endocrine Committee, and Shanxi Province Member and secretary of the Society of Medical Society's Orthopedic Loose and Bone Mine Salt Professional Committee, and a special medical expert in Wuzhai County First People's Hospital.

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