以社交網路服務增強智能照護模式:第五期慢性腎病之慢性照護模式新理論

Abstract

慢性病照護模式將慢性病照護管理將獲得醫療保健服務的社區以及涉及醫療系統中。強調了“自我管理支持”的重要性-讓患者了解自身管理狀況的知識，信心和技能。“健康服務輸送系統”對於促進以患者為中心的跨學科團隊照護方法也很重要。需要“決策支持”以確保提供者和患者能夠獲得最新和相關的基於證據的指南。最後，該模型強調“臨床資訊系統”的作用，以提供對所需數據，信息和知識的採用。改善健康。有效且富有成效的患者和提供者互動是慢性病照護模式的核心，也是改善結果的關鍵。 目標：第五期慢性腎病的患者，有較高的風險，進入透析及尿毒併發。由於提早開始透析無法延長壽命且開始常規血液透析時腎功能較高者，透析後存活率反而較低在透析開始前周全準備透析通路，能改善透析預後並節省支出。這些證據皆指出，故現階段開始透析的主要考量，仍建議以臨床出現無法以藥物控制的尿毒症狀或末期腎臟病併發症，亦即以臨床症狀為主，生化檢驗為輔。 方法：本研究是經由網際網路通訊科技的方式，來協助慢性腎病第五期的患者，和主責醫師有更佳醫病的溝通，安全延緩進入透析的時間，以慢性照護模式加上新的通訊科技，提供是最佳照護模式 結果：在我們的研究中有社交網路服務的病患有較晚進入透析的時間(761.7 ±616.2 days)。在基礎腎功能（eGFR）調整後，有社交網路服務的患者有統計上意義的延緩了每eGFR下降一個單位天數（84.8±65.1天）比其他組更長，且較晚進入透析的時間，延緩了約417天。 結論：第五期慢性腎病的患者經由以社交網路服務增強智能照護模式可以解決溝通的差距，為慢性腎病創造更多的益處，可以安全的延遲透析的開始。本研究是經由網際網路通訊科技的方式，來協助慢性腎病第五期的患者，和主責醫師有更佳醫病的溝通，安全延緩進入透析的時間，以慢性照護模式加上新的通訊科技，提供是最佳照護模式。

Background: CKD stage V is a high risk for dialysis initiation and complication such as uremic encephalopathy, uremic symptoms, gastrointestinal bleeding and infection. IDEAL trial provides guidance on the safety of waiting for symptoms or lower levels of estimated glomerular filtration rate prior to beginning dialysis. There was a serious communication gap during CKD stage V care. Objective: Our aim was to establish a powerful care model with Social Networking Services (SMS) to improved care quality in health care and dialysis initiation. Methods: Our study is retrospective cohort from 2007 to 2017. The patient age is between 20-85 years. In 2014, Dr H started to use with SMS app to connect with CKD stage V patients and their family. In case of emergency, the patients and their family can report any condition to Dr H. Dr H help promote the “productive interactions” between CKD stage V patients and Healthcare system. End point is to delay initiation of dialysis therapy with safety. Patient divided to four group, Team during 2007 to 2014(Team), Dr H during 2007 to 2014( Dr H), Team without SMS(Team-mob) during 2014 to 2017 and Dr H with SMS(Dr H +mob). Results: In our study, 4 group patients have different time to dialysis. Before adjusting, Group “Dr H +mob” had longer time to dialysis (761.7 ±616.2 days) than another group (vs Team p=0.011*, vs Dr H p=0.039*, vs Team-mob p=0.049*) . After adjusting with baseline eGFR , “Dr H +mob” had prolonged more duration of each eGFR drop (84.8 ±65.1 days) than other group (vs Team p=0.005*, vs Dr H p=0.032*, vs Team-mob p=0.002**) . Conclusions: SMS in Chronic stage V patients and physician can resolve the gap of communication and create more benefits for Chronic kidney disease to delay initiation of dialysis. Therefore, the role of SMS and the associated care model should be further investigated in more large population. Trial Registration: The study has been approved by the ethical review board of National Taiwan University Hospital (NTUH 201901030RINB and 201903005RINA).