Centre for Chronic Disease, University of Queensland, Queensland.
Aust N Z J Public Health. 2010 Feb;34(1):11-8. doi: 10.1111/j.1753-6405.2010.00467.x.
To report the short-term experiences and outcomes of a program to support chronic disease management in three remote communities in Top End Northern Territory and in two Aboriginal Medical Services (AMSs) in Western Australia, and to discuss the implications of findings for health service delivery and policy.
Programs were health-worker centred. They espoused regular screening of all adults for chronic disease, initiation and modification of treatment where indicated and rigorous documentation. Process measures were documented and rates of hypertension, renal disease and diabetes among adults were calculated.
Rates of hypertension, proteinuria and diabetes rose throughout adult life and multiple diagnoses were common. Most people with these conditions were young or middle age adults. Rates were uniformly excessive relative to AusDiab data, but varied greatly among settings. Adherence to protocols improved, many new diagnoses were made, treatments were started or modified and blood pressures in treated hypertensive people fell. In the NT, productivity was seriously limited by lack of health workers and their absenteeism. In the WA AMSs, executive and staff support carried the programs forward to a sustainable future, despite various challenges.
Integrated chronic disease testing must be repeated throughout adult life for timely diagnosis. Health workers can perform all tasks well, with appropriate supports. Blood pressure outcomes alone predict lower cardiovascular and renal mortality. The findings support incorporation of chronic disease into lifetime health care plans.
报告在北领地北部顶端的三个偏远社区和西澳大利亚的两个原住民医疗服务机构（AMS）中支持慢性病管理的计划的短期经验和结果，并讨论这些发现对卫生服务提供和政策的影响。
这些计划以卫生工作者为中心。它们主张对所有成年人进行常规慢性病筛查，在有需要时启动和修改治疗方案，并严格记录。记录了过程指标，并计算了成年人中高血压、肾脏疾病和糖尿病的发病率。
高血压、蛋白尿和糖尿病的发病率在整个成年期都在上升，并且多种诊断很常见。大多数患有这些疾病的人都处于年轻或中年。与 AusDiab 数据相比，这些发病率普遍过高，但在不同环境中差异很大。对方案的依从性有所提高，做出了许多新的诊断，开始或修改了治疗方案，接受治疗的高血压患者的血压下降。在北领地，由于卫生工作者的缺乏及其缺勤，生产力受到严重限制。在西澳大利亚的 AMS 中，尽管面临各种挑战，但行政和员工的支持使这些计划得以持续发展。
必须在整个成年期重复进行综合慢性病检测，以便及时诊断。卫生工作者在适当的支持下可以很好地完成所有任务。仅血压结果就可以预测较低的心血管和肾脏死亡率。这些发现支持将慢性病纳入终身保健计划。
