Balabanova Dina, McKee Martin, Koroleva Natalia, Chikovani Ivdity, Goguadze Ketevan, Kobaladze Tina, Adeyi Olusoji, Robles Sylvia
The Health Systems Development Programme, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, United Kingdom.
Health Policy Plan. 2009 Jan;24(1):46-54. doi: 10.1093/heapol/czn041. Epub 2008 Dec 12.
Effective delivery of diabetes care requires integration across specialist teams delivering recognized interventions, a reliable pharmaceutical supply, and promoting self-management. Drawing on a framework incorporating physical, human, intellectual and social resources, the paper examines how these challenges are managed in diabetes care in Georgia.
The rapid appraisal study triangulated data from interviews with users, providers and key informants from various institutions in four regions of Georgia; data on clinical and social outcomes from diabetes; legislative and policy documents.
Diabetes-related mortality in Georgia is among the worst in Europe and Central Asia, in a context of conflict, economic collapse and weak institutions. Essential inputs for diabetes care are in place (free insulin, training for primary care physicians, financed package of care), but constraints within the system hamper the delivery of accessible and affordable care. There are no evidence-based guidelines on diabetes management, formal support and quality assurance. The scope of work of primary care practitioners is limited and they rarely diagnose and manage diabetes, which instead takes place within the vertical system. Access to insulin is problematic in rural areas. Obtaining syringes, supplies and hypoglycemic drugs and self-monitoring equipment remains difficult everywhere. Prevention and effective management of complications is limited, increasing adverse outcomes. Diagnosis and treatment of diabetes complications involve hospital admission and unaffordable out-of-pocket payments. The complexity of pathways to key stages of care obstructs continuous care. There are poor linkages between primary and secondary care and ineffective patient follow-up or monitoring of outcomes. There is little effort to promote self-care, adherence to drug regimens and appropriate lifestyle, or to empower patients.
Improving diabetes outcomes will involve simplifying pathways to care and drugs, reassessing staff roles and insulin distribution systems. This would require better co-ordination of the inputs into the system and development of an integrated and patient-centred model.
有效的糖尿病护理需要各专业团队整合提供公认的干预措施、可靠的药品供应并促进自我管理。本文借鉴一个包含物质、人力、知识和社会资源的框架，研究了格鲁吉亚如何应对糖尿病护理中的这些挑战。
快速评估研究综合了来自格鲁吉亚四个地区不同机构的使用者、提供者和关键信息提供者的访谈数据；糖尿病临床和社会结局数据；立法和政策文件。
在冲突、经济崩溃和机构薄弱的背景下，格鲁吉亚的糖尿病相关死亡率在欧洲和中亚地区是最差的之一。糖尿病护理的基本投入已经到位（免费胰岛素、基层医疗医生培训、有资金支持的护理套餐），但系统内部的限制阻碍了提供可及且负担得起的护理。没有关于糖尿病管理、正式支持和质量保证的循证指南。基层医疗从业者的工作范围有限，他们很少诊断和管理糖尿病，糖尿病管理反而在垂直系统内进行。农村地区获取胰岛素存在问题。在任何地方，获取注射器、用品、降糖药和自我监测设备仍然困难。并发症的预防和有效管理有限，不良结局增加。糖尿病并发症的诊断和治疗需要住院，且患者需承担难以承受的自付费用。关键护理阶段的路径复杂性阻碍了持续护理。基层和二级护理之间联系不佳，患者随访或结局监测无效。在促进自我护理、坚持药物治疗方案和适当生活方式或增强患者能力方面几乎没有努力。
改善糖尿病结局将涉及简化护理和药物路径、重新评估工作人员角色和胰岛素配送系统。这将需要更好地协调系统投入并开发一个综合的、以患者为中心的模式。
