Chronic disease management standard requirements

The core essence of chronic disease management regulations has never been a set of one-size-fits-all implementation manuals, but a dynamic implementation framework centered on the three core anchors of "full-cycle layered intervention, individualized program adaptation, and multi-party responsibility closed loop" that takes into account evidence-based evidence and patients' actual quality of life.

Last week, when I was doing a chronic disease ledger check at a community health service center in Xicheng District, I happened to meet Director Wang of the general practice arguing with the follow-up nurse: "Aunt Zhang's plan for high blood pressure control is to follow the 140/90 control target. Don't bother with the 130 required by the guide. She is 82 and has an old cerebral infarction. The last time it was reduced to 128, she fainted and fell at home. Can you afford it?"

This incident just highlights the differences between the two schools that have been controversial in the field of chronic disease management: the evidence-based school insists that all intervention actions must be in line with the rigid indicators of the latest domestic and foreign guidelines. For example, patients with type 2 diabetes must control their glycated hemoglobin below 7%, and must complete three screenings of fundus, renal function, and urine microalbumin every year. Statin Drugs must be taken as long as there are no absolute contraindications; the humanistic school believes that the core of chronic disease management is to improve the patient's quality of life. If the patient's muscles hurt after taking statins and he can't even go downstairs, then it is better to change to a mild lipid-lowering plan. Even if the glycation level is 0.5% higher, at least he can go out for a normal walk, pick up his grandson from school, and live a busy life. There is no absolute right or wrong between the two views, so the current national regulations deliberately leave enough flexibility and never require everyone to perform according to the same standards.

Of course there are hard bottom lines that cannot be touched. For example, people over the age of 35 must have their blood pressure and blood sugar measured during their first visit. This is clearly written into the basic public health requirements by the National Health Commission and there is no room for negotiation. In the files of patients diagnosed with chronic diseases, allergy history, past major medical history, and drug contraindications must be written in the most conspicuous position on the home page. Any omission will be considered a failure. There is also a referral channel for emergency cases that must be opened: if the patient's blood pressure suddenly spikes to 200/120 accompanied by headache and nausea, or the blood sugar is so high that no ketone body test is positive, and the community cannot handle it, he must be able to contact the green channel of the higher-level hospital within 15 minutes. This is a hard line, and if there is a problem, he will be held accountable.

Don’t think that the regulations are all constraints. Many flexible parts test the ability of the executor more than the hard requirements. Let’s talk about the frequency of follow-up visits. There is never a strict rule that high blood pressure and diabetes must be visited once a quarter. For a young person who has just been diagnosed, he can’t control his words and likes to stay up late. It’s not too much to call him once a week to remind him. For an old patient in his 70s who has been taking medication regularly for 10 years, his blood pressure and blood sugar are extremely stable every time he checks, so a six-monthly follow-up visit is fully in line with the requirements. There is no need to have a unified template for lifestyle guidance. Don’t just ask patients with chronic diseases to “eat light and walk 10,000 steps a day” - gout patients should eat less high-purine soy products, and hypertensive patients with normal kidney function should eat some tofu to supplement high-quality protein. For patients with degenerative knee lesions, if you let them practice silent squats at home and swim twice a week, it is much better than forcing them to walk 10,000 steps and hurt their knees.

In order to cope with the assessment, there was a village doctor in the suburbs who prescribed the same ACEI antihypertensive drug to all hypertensive patients in the area without following up on the reaction of the drug. One patient had a dry cough for half a year after taking it, and it was not until he was hospitalized that he developed pneumonia and found out that it was a side effect of the drug. This is a typical example of only doing superficial work and completely missing the core of the specification.

To be honest, I have been working on chronic disease management for almost five years. I have seen too many people fill in false data in order to improve the management rate. I have also seen community doctors who record the taboos of chronic disease patients in their jurisdiction, contact information of their families and even the birthdays of their grandchildren in their follow-up books. The complication rate of the patients managed by the latter is more than 30% lower than that of the former. In fact, norms are dead, but people are alive. As long as you remember that chronic disease management is not about the disease, but about people, and to make patients live longer and comfortably, no matter what you do, it won't be too outrageous.

Oh, by the way, in the revised draft of the "National Basic Public Health Service Standards (Third Edition)" that is currently soliciting opinions, many one-size-fits-all quantitative indicators have been changed to flexible requirements, and a description of "adjusting the intervention plan according to the actual situation of the patient" has been specially added. To put it bluntly, the best standard is never an instruction manual for you to follow. It just helps you draw the bottom line that you cannot step on. The remaining space is originally reserved for you to tailor a plan for each patient.