黄小琼　周文哲　蒋丹丹　唐媛　林豪　梁优萍　陈燕燕

[关键词] 青光眼;个案管理;系统开发;应用效果

[中图分类号] R775          [文献标识码] B          [文章编号] 1673-9701（2021）17-0171-04

Study on the development and application effect of case management system for glaucoma patients

HUANG Xiaoqiong1   ZHOU Wenzhe1   JIANG Dandan1   TANG Yuan2   LIN Hao1   LIANG Youping1   CHEN Yanyan1  1.Department of Nursing， Eye Hospital， Wenzhou Medical University， Wenzhou   325000， China; 2.Eye Hospital， Wenzhou Medical University， Wenzhou   325000， China

[Abstract] Objective To design and develop a case management system for glaucoma patients and study its application effects. Methods From January 2018 to December 2019， 1000 glaucoma patients were randomly included before and after the development of glaucoma case management system. The results of five sensitive indicators before and after the development of the case management system were compared and analyzed， including the completion degree of the examination， the rate reaching the target intraocular pressure， the compliance with follow-up ， the follow-up rate and the patients′ satisfaction. Results After the development of the glaucoma case management system， the inspection rate of designated items before diagnosis and treatment increased from 70% to 97%. The rate reaching target intraocular pressure increased from 0% to 67%. The compliance with follow-up increased from 28% to 67.5%. The follow-up rate increased from 30% to 73.4%; and patients′ satisfaction increased from 95% to 99.5%， and the differences were statistically significant （P<0.001）. Conclusion The development and application of the system provide a powerful systematic guarantee for the continuous nursing and lifelong follow-up of glaucoma chronic ophthalmopathy. The continuous monitoring of the five sensitive indexes has effectively curbed the further development of glaucoma and made positive contributions to accurate diagnosis， treatment and nursing.

[Key words] Gaucoma; Case management; System development; Application effect

青光眼是一组以特征性视神经萎缩和视野缺损为共同特征的疾病[1]，病理性眼压增高是其主要危险因素[2，3]。它会导致视野和视神经的不可逆损害，这种损害很难恢复，且会有继续发展的可能[4]。它是仅次于白内障的全球第二位致盲性眼病[5]。青光眼患者具有疾病認知水平低、随访依从性差、用药依从性低、致盲率高等多重特点[6，7]，因此对现有的青光眼管理提出了挑战。规律的随访对于医生监测青光眼病情进展、及时调整治疗方案以及预防视力损伤至关重要[8]。研究发现个案管理模式有利于质量控制临床路径，加强医患沟通，同时改善患者的生存质量、满意度、治疗随访依从性等医疗结局[9]。因此，我院于2015年起将个案管理模式应用于青光眼疾病，根据多份青光眼指南制定出适合本院的临床路径。医生根据临床路径针对青光眼的诊断、治疗及随访进行标准化管理。青光眼医生为患者设定目标靶眼压和治疗计划，由个案管理师对病情稳定的患者进行随访。在个案管理中，为保障眼科患者能及时有效的相互监督、信息交流及管理工作的全面性、及时性、准确性、高效率开展，个案管理必须借助一套科学、完整的系统进行精细化管理[10]。目前国内文献尚未见完整的眼科个案管理系统的报道，市场上也无法购置此类软件。……