Introduction:
Chronic Kidney Disease (CKD) has become one of the major public **** health problems in China due to its high prevalence and incidence, and CKD patients, once progressing to end-stage renal disease (ENDSRD), have to rely on renal replacement therapy (RRT) to sustain their lives for a long period of time at a very high cost. Currently, CKD patients only rarely get face-to-face guidance from renal specialists, and rely on self-management and care for most of the time. With the further development of information technology, what is the current status of the application of "Internet+" in the integrated management of chronic kidney disease? Below, I will lead you to see the insights of Prof. Fu Ping from West China Hospital of Sichuan University.
China's heavy burden of CKD
Prof. Fu Ping pointed out that CKD, as a major public **** health problem in China, is mainly manifested in the following four aspects:
(1) high prevalence rate: the data show that , there are 697.5 million chronic kidney disease (CKD) patients worldwide*** in 2017, of which, nearly one-third of CKD patients are in China and India, with a prevalence of 132 million and 115 million, respectively. The average prevalence of CKD among adults in China is 10.8%, with the Southwest region (18.3%), represented by Sichuan Province, leading the way.
(2) Closely related to poor prognosis : Once CKD progresses to ESRD, the risk of death is 10 20 times higher than that of people with normal kidney function. According to statistics, in 2017 alone, CKD caused 1.2 million deaths worldwide (the 12th leading cause of death worldwide).
(3) The incidence of CKD and ESRD continues to climb : China's aging, diabetes, hypertension, heavy burden of disease, diabetes has jumped to the first cause of CKD in China, urban residents with diabetes as the primary disease of CKD patients up to 32.7%. According to statistics, in 2019 the number of hemodialysis in China has reached 710,000 people.
(4) High health care expenditure : According to the 2015 China Kidney Disease Data Network Annual Report data, the total medical expenditure for dialysis patients was 429 million yuan (76.6% paid by medical insurance). Hemodialysis and peritoneal dialysis patients only accounted for 0.16% and 0.02% of all health insurance patients, but accounted for 2.1% and 0.3% of total health insurance expenditure. Patients with normal or mildly decreased renal function make up the majority of all CKD patients. If this group of patients is managed effectively in the long term, delaying access to dialysis will save healthcare resources to a great extent. If the Internet technology and platform can be effectively applied to the management of this large group of CKD patients, it will greatly enhance the effect of chronic disease management and effectively reduce the health burden.
Inadequacies in China's chronic disease management model for CKD
According to Prof. Fu Ping, because of its long-term nature, gradual progression, multiple risk factors, and poor prognosis, CKD needs to be intervened in the long term from early screening, prevention and treatment, controlling complications, slowing down the deterioration of renal function, and improving the quality of life of patients. In the early years, there was no sufficient cost data and health economics data to support the management of CKD (especially end-stage dialysis patients), which led to the late start of the management of CKD chronic disease in China, and the work is complicated and time-consuming, and there are many aspects that need to be further improved:
(1) The waiting time for patients to be seen in the clinic is long, but the counseling time is short, which leads to the lack of patient education and the existence of patients with inadequate lifestyle and medication.
(2) The overall management model is not well planned, and the allocation of medical resources is not rational;
(3) Most CKD management models focus on medical interventions rather than prevention;
(4) The prescriptions of medications for CKD patients are complex and ineffective;
(5) Patients with CKD receive emergency treatment rather than long-term care;
These patients have been given a lot of care and attention. care;
(6) hemodialysis centers lack an effective quality control system and an open service evaluation system;
The current status of the application of "Internet+" in CKD management
Smart consultation, payment based on the Internet technology platform, Diagnostic and follow-up models based on Internet technology platforms are very common, and Prof. Fu Ping briefly describes the current status of the application of "Internet+" in the following aspects.
01
Intelligent diagnosis
Artificial Intelligence (AI)-based clinical decision-making systems are gradually being applied to clinical practice, with high diagnostic and predictive efficacy.
Computer algorithms are more reproducible and accurate than manual observation, and are better able to recognize fine pathological changes. The automated evaluation process is labor-saving and is feasible because it is based on a large sample study of pathologic diagnoses. In predicting renal function decline, the convolutional neural network algorithm performs better than the pathologic assessment results of the traditional pathology scoring system in predicting renal survival, creatinine level, and urinary protein in CKD patients. At the same time, the algorithm can more accurately identify the individual characteristics of CKD patients, and by utilizing the integrated e-medical database of CKD patients and existing technologies, we can also identify CKD-related risk factors and intervene in advance, and intervene early in the onset and progression of CKD at the level of primary and secondary prevention. Current prediction methods in the field of kidney disease are mainly artificial neural networks, decision trees and Bayesian belief networks, and the vast majority of studies utilizing the above methods are able to predict kidney failure events with high sensitivity and specificity.
02
Standardized follow-up
From the point of view of the construction of the clinical follow-up database, the current CKD intelligent follow-up model still exists in the following shortcomings: (1) There are many different types of APPs, which compete with each other. The CKD patients' follow-up data cannot be managed in a unified way; (2) the health records and follow-up data are created and entered by the patients themselves, and the reliability of the data sources and the accuracy of the data entry are yet to be further verified. At the same time, due to data security considerations, the follow-up data of these CKD patients can not be connected to the hospital information system, which directly affects the integrity and feasibility of the clinical research on CKD patients.
For CKD patients, scientific follow-up design and long-term patient compliance are very important. In recent years, China has developed a wide range of follow-up management software specifically for CKD, but the functions and user objects are basically similar. The main function of the patient's client is to create a personal health information file, enter vital signs, test results, symptoms and medication information, and the follow-up software will give timely feedback and medical advice on changes in health data (e.g., warnings about abnormalities in blood pressure, creatinine, hemoglobin, etc.).
03
Dialysis Center Management
ESRD patients are expensive to treat with dialysis, so they should choose a treatment model that has low medical costs, excellent treatment effects, and helps patients return to society. Peritoneal dialysis has these advantages, but is not a clinical priority due to the relative lack of medical resources in China. Internet+" three medical linkage of peritoneal dialysis center management mode is recommended in recent years in China's reform, based on the medical, health insurance and pharmaceutical three **** together to standardize the management of peritoneal dialysis in the operation and management of a high degree of use of the "Internet +" technology, the instrument will be used in the operation and management of the "Internet +" technology, the instrument will be used in the operation and management of the "Internet +" technology.
These are the first time I've ever seen a patient in a hospital in the United States, and I've never seen one in the United States.
Experience of the CKD Management Center at West China Hospital
The development of the CKD Management Center of the Department of Nephrology at West China Hospital of Sichuan University*** has gone through the five journeys of building the center, constructing the system of patient education, improving the quality, launching the software management system, and providing nursing training in various aspects of clinical and scientific research.
Currently, the center has about 1600 patients on file for follow-up, forming a larger CKD follow-up center with physicians, nurses, and dietitians. The center's MDT team guides CKD patients throughout the process of diet, lifestyle habits, medication use, and pre-preparation of vascular access. Regular follow-up includes demographic variables, vital signs, various examination indicators and regression, tracking and improving the quality of life of CKD patients from various aspects. Under this model of management intervention, the volume of vascular access procedures for CKD patients in the Department of Nephrology, West China Hospital, Sichuan University, increased significantly (endovascular fistulae, number of central venous cannulas, and vascular access interventions increased), the volume of outpatient visits to CKD specialties increased significantly, and the average hospitalization days and the proportion of drug costs of CKD patients decreased significantly during the same period.
The CKD Management Center of Nephrology was established in August 2011, and has set up a follow-up team, formulated the follow-up process, established follow-up files, developed a regular monthly series of CKD patient education lectures since March 2012, and held the first patient meeting of the CKD Management Center in December 2012, and launched the follow-up software system of the CKD Management Center in June 2013, and started the CKD Specialized Outpatient Clinic. At the same time, the Nephrology Nurse Specialist Training Program was started to improve the level of inpatient patient education and outpatient follow-up compliance, as well as to gradually prepare for the follow-up of patient teachers.
Although the CKD Management Center of the Department of Nephrology at West China Hospital of Sichuan University has been established for 10 years, there is a lack of teaching staff and a serious shortage of human resources. Although the CKD follow-up software system has been activated since June 2013, the software system is slow to update, the database is relatively independent, the operational capacity is far from meeting clinical needs, and 85% of the outpatients are out-of-town patients, making it difficult to maintain patient compliance. In August 2020, with the help of Scholastic, a new follow-up management software system has been put on line, which, with the support and backing of the whole hospital's smart hospital construction, will dramatically increase the number of patients under follow-up management in a short period of time, facilitate the process of follow-up, and accelerate the construction of the research database.
"Internet +" in the integrated management of CKD application prospects
The integration of the information system is the basis: medical electronic medical record system, doctor-patient information interaction information system (including chronic disease-related follow-up, remote monitoring), Medical expert decision-making early warning system, public **** health, drug and even insurance systems will continue to be integrated, to build the most comprehensive CKD medical database to make structural paving.
The application of "Internet+" in CKD management will penetrate into the community to help integrate and ****enjoy the health records of community residents, laying down the Internet architecture for the CKD universal education management and reducing the first level of prevention of disease occurrence. Based on the comprehensive medical database, the use of artificial intelligence to analyze the future gap in medical resources and provide guidance and suggestions for the development and improvement of medical policies will effectively integrate CKD medical resources. The current "Internet+" model is gradually upgraded to "Internet of Things+" model, which can accurately identify, locate, monitor and manage smart devices in real time, which will greatly facilitate future CKD telemedicine, intelligent self-management of patients and effectively improve the quality and effectiveness of any treatment involving instrumental testing. This will greatly facilitate future CKD telemedicine, intelligent patient self-management, and effectively improve the quality of any treatment involving instrumentation (e.g., dialysis).
We should fully integrate the application of "Internet+" and "Internet of Things+" technologies in chronic disease management and establish a unified platform for CKD patient management services. Even the emergence of Chinese CKD chronic disease management Kaiser model: medical services and health insurance as one of the medical group, with health services and cost control of the dual advantages, covering disease prevention, disease diagnosis and treatment to the after-sickness rehabilitation of the whole process, with a view to further for China's chronic disease management, the formation of the doctor group and the payment model to bring about subversive changes in the control of the cost at the same time to enhance the level of health care services, Improve the prognosis and survival of patients. At the same time, the future of hemodialysis is expected to be grouped and networked, with tertiary-level hospitals as the main axis, radiating a number of community hemodialysis centers, establishing a transparent and open quality control system, and further realizing precise service management for patients with various stages of CKD.
Summary:
The nephrologist is the leader of the integrated management of CKD, patient education is a key link in CKD follow-up, a full-time patient educator is a core member of the follow-up management, the dietitian is an important part of the follow-up team, and mental health doctors and rehabilitation therapists, who are to be added to the follow-up system, are important support and supplementation. The mental health doctors and rehabilitation therapists will be added to the follow-up system as an important support and supplement. Internet technology and platforms are the hubs that connect all of the above, and are necessary to provide convenient follow-up, build high-quality medical databases, and promote research output. With the accelerated construction of the national three-tiered diagnostic and treatment system and the strong promotion of the policy of sinking high-quality medical resources, and by making full use of the powerful power of "Internet+", we will surely usher in a new round of spring for the management of chronic diseases in CKD.