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A comprehensive prevention and control mechanism for chronic diseases is taking shape.
Kong Lingzhi, Deputy Director of Disease Prevention and Control Bureau of Ministry of Health.
The situation of prevention and control is grim
In September this year, the 66th United Nations General Assembly held a high-level meeting on the prevention and control of non-communicable diseases, which was the second high-level meeting on health in the history of the United Nations after the AIDS prevention and control meeting held by the General Assembly in 20001. The political declaration adopted at the meeting pointed out that chronic non-communicable diseases are one of the severe challenges facing the development of countries in the 2/kloc-0 century. To deal with chronic diseases, the government must bear the main responsibility, and all sectors of society must strive to encourage the formulation of multi-sectoral policies, create a fair environment for promoting health, and enable individuals, families and communities to make healthy choices.
At present, the incidence of chronic diseases in China is very serious. The monitoring data of chronic disease behavior and risk factors of residents aged 65,438+08 and above in 2065,438+08 show that excessive salt and oil intake is a very prominent problem. 80.9% of families have a daily salt intake of more than 5 grams per capita; 83.4% families eat more than 25 grams of oil every day. /kloc-among the residents aged 0/8 and above, only 1 1.9% exercise regularly, the overweight rate is about 30%, and the obesity rate is about 10%. There are over 200 million patients with hypertension and over 30 million patients with hypercholesterolemia. The prevalence of diabetes reached 9.7%. The incidence and mortality of cancer are rising, and the proportion of premature death caused by chronic diseases accounts for 57.8%. Chronic diseases account for about 70% of all diseases.
Actively seek a new way out
20 1 1 the world economic risk assessment report points out that chronic diseases can not only bring down the national medical system, but also brake the national economy. How to deal with the problems and challenges faced by the prevention and control of chronic diseases in China needs constant exploration.
■ First, top-level design is required. China has not yet issued laws and national policies for the prevention and treatment of chronic diseases; Lack of investment in chronic disease prevention. At present, although the country has invested a lot of scientific research funds, the prevention of chronic diseases, especially chronic diseases, has not been given priority. From 2005 to 20 10, the funds paid by the central government for cancer prevention and treatment increased significantly, but the investment in infectious diseases and chronic diseases was still unbalanced, with the ratio of 100 1. In a large number of medical expenses, the cost of late treatment of chronic diseases accounts for the vast majority. Taking diabetes as an example, statistics show that more than 80% of the expenses are used for the treatment of diabetes.
In addition, actions such as creating a healthy city are still spontaneous actions in various places, and the coverage and influence of the construction of comprehensive prevention and control demonstration zones for chronic diseases are limited.
■ The second is to solve the related problems in basic public health services such as health management. For example, many residents' health records have become dead files and the utilization rate is low. In this regard, the Ministry of Health requires that the filing rate reach 50% by the end of this year, with special emphasis on standardized use; At present, health management of hypertension and diabetes in people over 35 years old is carried out in the community. By June of 20 1 1 year, only 2 1% of hypertensive patients and 12% of diabetic patients were managed, which needs to be accelerated.
■ Third, the prevention and control system needs a coordination mechanism. At present, the prevention and treatment of chronic diseases are scattered in medical institutions, disease control, health education, maternal and child health care and other institutions, and the National Cancer Center, National Cardiovascular Center, prevention and treatment offices at all levels, various societies and other organizations also undertake corresponding tasks. In order to form a joint force, we should establish a coordination mechanism within the health department and between technical institutions, encourage local municipal and district disease control systems to set up chronic disease departments (institutes), and encourage local governments to set up disease prevention centers or demonstration bases in medical institutions, so as to give full play to the role of academic groups and make all kinds of prevention and control forces form a joint force.
Optimize the choice of intervention measures
Professor Zhao Kun, Health Development Research Center of Ministry of Health
■ The overall allocation of health funds is inefficient.
Scarcity of health resources is a challenge to any country, and how to make good use of scarce health funds is an urgent problem for all countries. According to the calculation of the total health expenditure by the Health Development Research Center of the Ministry of Health, 70% of the expenditure is invested in medical services. The calculation of chronic diseases in Tianjin and Gansu province shows that more than 83% of the expenses are used for clinical treatment and less than 2% for public health, which shows that only a small part of the expenses are used for disease prevention. The cost of prevention and management of chronic diseases is too small, which means that the disease burden driven by chronic diseases is increasing year by year, indicating that the overall allocation of funds is inefficient.
It is found that the treatment expenses of chronic diseases are mainly used for the treatment of cardiovascular and cerebrovascular diseases, diabetes and tumors. Among them, the direct medical expenses of cardiovascular and cerebrovascular diseases have been in the forefront, and its growth rate is much faster than the growth rate of GDP in the same period.
■ The priority of fund allocation should be clear.
A large number of evidence-based medical studies have proved that 60% of deaths are related to chronic diseases, and 70% of chronic diseases can be controlled through prevention. According to the report "Building a Healthy and Harmonious Life" released by the World Bank in July this year, if the annual mortality rate of cardiovascular and cerebrovascular diseases in China is further reduced by 1 percentage point, taking into account the inherent value of life expectancy per capita, the annual economic benefit equivalent to 2065 GDP 19% will be 438+00, which is about 807 billion US dollars. If the mortality rate of cardiovascular diseases is reduced by 3%, the annual economic benefit in 20 10 will reach 48% of GDP, which is about 1.86 trillion US dollars.
Because only 2% of the expenditure on chronic diseases is used for public health, two principles should be followed when allocating health resources, one is clinical effect, and the other is cost effect. At the same time, according to the occurrence and evolution of diseases, the prevention and treatment of diseases are divided into four stages. The first stage is primary prevention, through health education and health promotion to avoid risk factors. The second stage is secondary prevention, through screening and health examination, to achieve early detection and early treatment; The third stage is disease treatment and early rehabilitation; The fourth stage is stability and recovery. Each stage will have different interventions and treatment programs. What measures are most effective and cost-effective? Which interventions and treatment programs have the greatest contribution to reducing mortality? In the case of limited resources and funds, priority can only be given.
The cost-effectiveness study of stroke unit therapy conducted by the Health Development Research Center of the Ministry of Health in cooperation with Beijing Tiantan Hospital shows that every time the stroke unit group spends 1 minute less medical expenses than the general ward group, it spends 509.9438+0 yuan less. Compared with the general ward group, the stroke unit group spends 720.88 yuan less on medical expenses every time the level of living disability is reduced by 1 level. Compared with the general ward group, the stroke unit group spends 42.6 yuan less on the score of daily living ability for every 5 points. From this point of view, under the premise of ensuring the quality of prevention, treatment and rehabilitation, it is a rational choice to choose the treatment method with the least cost.
Generally speaking, the first criteria for determining the priority of health fund allocation are safety, effectiveness, heavy disease burden and social demand; The second criterion is to conform to social ethics and fair norms; The third criterion is cost-effectiveness or cost-effectiveness; The fourth criterion is economically feasible and organizationally feasible.
As far as the prevention and control of chronic diseases is concerned, for cancer, cardiovascular and cerebrovascular diseases, diabetes, hypertension and mental and psychological diseases, it is necessary to make clear which intervention and prevention technologies have the best cost-effectiveness or cost-effectiveness according to the economic affordability of the public. At the same time, we should consider whether these technologies are provided by disease control or maternal and child health care institutions, or by primary medical and health institutions or hospitals.
■ Explore a new model of diabetes management.
Ji Linong, Chairman of Diabetes Branch of Chinese Medical Association
In the past two or three decades, the prevalence of diabetes in China has increased significantly. At present, how to manage diabetic patients is a very big problem.
Recently, the Diabetes Branch of the Chinese Medical Association completed the data collation of the survey on the current situation of diabetes management. The survey not only covered different parts of the country, but also covered almost all levels of hospitals, with a total of 103 hospitals and more than 25,000 respondents. The preliminary results of the survey show that diabetes is not a geriatric disease, and 54% of outpatients with diabetes are under 65 years old.
The survey found that the diabetic population in China not only has the problem of hyperglycemia, but most people also have the problem of blood lipid metabolism and blood pressure. The average level of low-density lipoprotein cholesterol, the most important indicator, is 2.86%. If low density lipoprotein 2.6 is taken as the basic standard, the compliance rate of the investigated population is only 40%. From the occurrence of complications, the course of diabetes is less than 1 year, nearly 20% people have microangiopathy, and 15% people have macroangiopathy; Among the people whose diabetes course exceeds 10 years, 50% have microvascular complications, and nearly 30% have macroangiopathy. The survey shows that the diabetic population is not only the population whose risk factors are not well controlled, but also the population with high incidence of complications, especially the patients with long course of disease. All these challenges the current diabetes management.
For patients with cardiovascular events, secondary prevention with aspirin and statins can significantly reduce the risk of coronary heart disease or death. However, the patient utilization rate in China is only 4%. The key measures are not up to standard, which is not a simple medical problem. There are problems with patients, problems with medical insurance policies, and problems in many links.
In disease management, a big problem that needs to be solved is to establish a model hospital and department for the management of diabetic patients. Through translational medicine research, these departments can implement standardized treatment in outpatient and community patient management, thus improving patient compliance and improving the implementation rate of standardized treatment. It is also important to formulate guidelines, but how to implement them needs to be studied. Through these studies, we can explore the experience of medical policy, continuing education strategy, behavior intervention and patient self-management, and influence the policy, doctor's behavior and hospital management system, so as to raise the management of chronic diseases in China to a higher level.
■ Diagnostic methods of diabetes should be changed.
Ning Guang, vice president of Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine, said.
20 10 China diabetes survey found that the incidence of diabetes in China is almost consistent with the growth of GDP per capita. The total number of diabetic patients in urban and rural areas is about 96.5 million, while the awareness rate of diabetic patients is 36. 1%. At the same time, 64% patients still don't know that they have diabetes. How should we find them?
At present, the diagnostic rate or awareness rate of diabetes in China is much lower than that of hypertension, mainly due to the problem of diagnostic methods. Eating 75 grams of glucose on an empty stomach, and then doing blood sugar two hours later, this diagnosis method is too complicated, which makes many patients lose. When fasting blood glucose is checked, only 1/3 patients can be found. Can it be detected by other methods? It should be determined by glycosylated hemoglobin. If glycosylated hemoglobin+fasting blood glucose is used to determine the diagnosis, the approximate coincidence rate of diagnosis is 87.6%. In other words, as long as blood is drawn 1 time in the morning, 90% of diabetic patients can be found. In this sense, there is no need to do blood sugar two hours after meals. Based on this study, can we first carry out large-scale fasting blood glucose and glycosylated hemoglobin tests to screen out diabetic patients before further diagnosis and testing? In this way, the detection rate of diabetes can be increased by 1 times.
Patients with chronic diseases will be reimbursed more for outpatient expenses.
Dong, Deputy Director of Medical Insurance Research Office of Ministry of Human Resources and Social Security Institute of Social Security
■ Outpatient payment system for serious illness is generally established.
Compared with 2009, in 20 10, there were more than 8,000 designated medical institutions and 5,000 designated pharmacies. Among them, the increased designated medical institutions are mainly grass-roots medical institutions below the first level, which is conducive to the front-end prevention and treatment of chronic diseases.
At present, most places have established outpatient serious illness payment system, which is paid by the overall fund. The survey shows that at present, more than 85% of the areas have implemented the policy of outpatient serious illness (chronic disease), but the catalogues vary greatly from place to place. According to the survey conducted by Ministry of Human Resources and Social Security Social Security Research Institute in 175 co-ordination areas in 2008, the smallest out-patient serious illness catalogue has only 1 disease, while the largest catalogue has 43 diseases. It is worth noting that the reimbursement for serious illness clinics is aimed at the complications of chronic diseases, and most of the funds are used to treat complications, not for the early prevention and treatment of chronic diseases.
■ Advance payment system urges hospitals to take the initiative to intervene.
At present, the problem with the payment policy of chronic diseases in medical insurance is that medical insurance pays for each treatment item under the condition of item payment, and both medical insurance and medical institutions only consider the immediate treatment effect and treatment cost. This management method is not suitable for the prevention and treatment of chronic diseases. However, under the mode of "unified account combination", personal accounts pay for general outpatient expenses. Under this fund structure, patients with chronic diseases are easy to make ends meet, and personal accounts are simply not enough to pay for chronic diseases. Moreover, the lack of medical insurance management for the general outpatient department of chronic diseases greatly reduces the compliance of chronic disease treatment.
In the second half of last year, Ministry of Human Resources and Social Security put forward two important measures for medical insurance reform, one is to explore outpatient co-ordination and the other is to reform payment methods.
In the long run, the overall development of individual account to outpatient service will make more medical insurance funds used for outpatient service and urge medical institutions to attach importance to outpatient service. The overall fund will pay for early chronic diseases, and the elderly and patients with chronic diseases will receive more reimbursement for outpatient expenses. However, the development from project-based payment to prepayment system and the implementation of per capita payment for chronic diseases in outpatient clinics will prompt medical institutions to take the initiative to pay attention to early intervention of chronic diseases and avoid large expenses.
In addition, the implementation of the prepayment system will encourage medical institutions to actively provide cost-effective chronic disease prevention and treatment services by enhancing their independent decision-making power.
A fair and efficient security and prevention system for chronic diseases should have two basic elements: one is to establish a fair security system through a statutory medical security system, and the other is to form an efficient prevention and treatment system through a competitive primary medical system. Advance payment system is an important mechanism to connect these two elements.
■ Guide patients to strengthen self-management.
Professor Dong Jianqun, Center for Chronic Diseases, China Center for Disease Control and Prevention
From 1950s to 1970s, the medical and public health systems in China were completely separated. Doctors only make diagnosis and treatment, while public health doctors only make prevention, which is out of touch with treatment. No one manages the risk factors of chronic diseases, and patients lack self-management of diseases. In recent years, the international community has strongly advocated changing this situation. At present, China is also working on system construction, improving disease prevention and control management, and building a comprehensive network for chronic disease prevention and control.
The so-called patient self-management means that patients are the main body, and with the assistance of health professionals, patients themselves undertake the main prevention, treatment and health care tasks. By mastering the necessary skills and means of prevention and treatment of chronic diseases, the quality of life of high-risk groups and patients can be improved and their healthy life can be prolonged.
The most important factor of self-management is to stimulate the potential of patients themselves, not just to give them information. Since 2007, the Center for Chronic Diseases of China Center for Disease Control and Prevention has been exploring this aspect. Since May this year, it has been exploring a new model of comprehensive diabetes management, applying advanced management concepts of diabetes prevention and control at home and abroad, and training 500 young and middle-aged backbone doctors and nearly 10,000 grassroots doctors in China on diabetes prevention and control knowledge within five years, so that clinicians can have the concept of public health; Select some national demonstration areas for comprehensive prevention and treatment of chronic diseases to carry out self-management activities for patients with hypertension and diabetes, and set up patient support groups, so that patients with diabetes and high-risk groups can master the knowledge and skills of self-management, help each other and get health together.
On the basis of establishing a network for the prevention and treatment of chronic diseases, it is necessary to explore appropriate technologies suitable for China's national conditions. According to the requirements of the Ministry of Health, the Center for Chronic Diseases of China Center for Disease Control and Prevention is gradually popularizing appropriate technologies for chronic diseases management, and integrating low-cost, high-efficiency, safe and reliable technologies suitable for popularization, including self-management, into the establishment of the national demonstration zone for chronic diseases prevention and control.
■ Give the most appropriate treatment at the early stage of the disease.
Bristol-Myers Squibb (China)/Peng Zhenke, President of Sino-American Squibb.
This is an exciting moment for diabetics and pharmaceutical companies, because everyone is concerned about the prevention and treatment of chronic diseases, especially diabetes.
At present, there are more than 90 million diabetic patients in China, but most of them are not well controlled. According to experts, in the 1990s, only 0.97% people in China suffered from diabetes, but now this figure is close to 10%. Diabetes is spreading rapidly, and we must curb its spread. Bristol-Myers Squibb will continue to introduce innovative drugs for this purpose, and hopes to actively participate in the prevention and management of diabetes in China.
Prevention is the key to the prevention and control of chronic diseases. According to the data, if you invest 1 yuan in prevention, you will save 6 yuan money in treatment in the future. The task of prevention is not only to get sick before, but also to give the most appropriate treatment at the early stage of the disease. This treatment should be effective with few adverse reactions. Amrit, a drug recently introduced by Bristol-Myers Squibb for the treatment of type 2 diabetes, can not only lower blood sugar, but also has high safety. It only needs to be taken 1 time every day, which is convenient for patients to take. In 20 14 years, we expect to launch two diabetes drugs. In addition, we will continue to support the training of doctors and patients, so that doctors can understand and master how to better manage diabetic patients, and educate patients to take medicine according to the requirements of doctors.
Preventing chronic diseases is a social responsibility. As a pharmaceutical company, we are committed to providing innovative drugs for patients. Disease prevention is a team work. We hope to cooperate with CDC, clinical experts and the media, and act now to fight against chronic diseases.
Point of view
Yin, Director of the Department of Disease Prevention and Control of the Health Department of Shanxi Province: By the end of September this year, Shanxi Province had standardized the management of 397,000 diabetic patients and 1.45 million hypertensive patients. First, combining prevention and treatment to serve the masses in the process of managing patients; Second, medical security is inclined to chronic diseases, and some subsidies are given to patients with chronic diseases in the new rural cooperative medical system; Third, pay attention to popularizing practical knowledge of disease prevention and treatment in rural areas and grassroots units.
Yang Jianhua, Deputy Director of Hangzhou Health Bureau, Zhejiang Province: There are two suggestions for the prevention and control of chronic diseases. First, in the establishment of chronic disease demonstration zones, the government should play a leading role and build a creation carrier at the national level. Second, the prevention and control of chronic diseases focuses on the community, making the community an important position for the prevention and control of chronic diseases.
Ding Xianbin, director of the Institute of Chronic Diseases of Chongqing CDC: The countryside is the main battlefield for the prevention and treatment of chronic diseases. It is very important to strengthen the construction of rural medical outlets, and rural doctors should be encouraged to provide public health services; Eliminate the blank area of chronic disease prevention and control. After the implementation of basic public health services, grass-roots units have conducted follow-up management for patients with hypertension and diabetes, but many of this management only measures blood pressure and blood sugar, and cannot really interfere with risk factors.
Chen, Deputy Director of Health Bureau of Nanchang City, Jiangxi Province: The formation of chronic diseases is a long-term process. Health education should start with children and start with mothers. It will be very helpful if my mother can understand and set an example. In addition, the prevention and control of chronic diseases advocates multi-sectoral participation, and the media should also actively participate.
Zou Dajin, a professor at Changhai Hospital of the Second Military Medical University: Chronic disease control cannot be separated from lifestyle changes and drug treatment. The government should further strengthen the promotion of healthy lifestyle; Large packaging of drugs should be encouraged to reduce the number and events of patients running to the hospital.
Feng Lizhong, executive deputy director of the Information Office of Anhui Provincial Health Department: There are three links in the prevention and control of diabetes: health education for normal people; Intervene in patients with early glucose tolerance problems or abnormal blood glucose indexes; Actively treat patients with complications. Prevention and control strategies of diabetes mellitus
We should pay attention to the second link and carry out preventive intervention.
Zhang Qingjun, deputy director of the Institute of Chronic Diseases of Hubei CDC: The country is implementing basic public health equalization services, and five of the 10 items are closely related to chronic diseases. The relevant provincial CDC, women's social departments and agricultural health departments should jointly carry out unified actions, which requires the establishment of an office from the health administrative level, located in a professional institution, to provide technical programs and assessment indicators, to co-ordinate the allocation of funds to the grassroots, and to supervise and assess the work in a unified manner.
Dong Zhong, director of the Institute of Chronic Diseases of Beijing CDC: We should integrate healthy elements into the whole urban construction. Since 2008, Beijing has a ten-year action plan to promote the health of Beijingers. In August this year, the "Twelfth Five-Year Plan" for the development and construction of a healthy Beijing was promulgated, and the deeper health promotion actions and 35 major indicators related to health and people's livelihood issues were identified as the core tasks. More than half of these 35 indicators are related to chronic diseases.
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