Ashton Chris W, Duffie Denise
HarbourFront Health Group, Grand Falls, New Brunswick.
Healthc Q. 2011;14(3):42-7. doi: 10.12927/hcq.2011.22489.
Chronic kidney disease (CKD) is a serious and growing threat to our First Nations peoples' health. Current evidence indicates more rapid progression of CKD in First Nations populations, leading to markedly increased morbidity and mortality. To address this serious health issue, three First Nations communities, Alderville, Hiawatha and Curve Lake, partnered with the Central East Local Health Integration Network (LHIN), the Peterborough Regional Health Center (PRHC) and local family and specialist physicians. A screening tool was developed based on reported best practices to screen all community members over the age of 19 years for CKD. A unique, highly efficacious project algorithm and an electronic database were created to ensure appropriate, seamless patient care and management in this complex, multi-stakeholder environment based on client risk and CKD stage. Over the course of nine months, the project succeeded in screening 83% of all community members over the age of 19 years; 30% of clients were found to have CKD stage two or greater. A strong correlation was found between diabetes and CKD in project participants. A significant number of clients were referred for specialist care. Critical to the success of this project was the effort made to develop collaborative partnerships among five stakeholder groups: the First Nations communities, the LHIN, PRHC, local family physicians and specialist physicians.
慢性肾脏病（CKD）对我们原住民的健康构成了严重且日益增长的威胁。现有证据表明，原住民人群中CKD的进展更为迅速，导致发病率和死亡率显著上升。为解决这一严重的健康问题，阿尔德维尔、希亚瓦萨和曲线湖这三个原住民社区与中东部地方卫生整合网络（LHIN）、彼得伯勒地区医疗中心（PRHC）以及当地的家庭医生和专科医生建立了合作关系。基于已报道的最佳实践方法开发了一种筛查工具，用于对所有19岁以上的社区成员进行CKD筛查。创建了一个独特且高效的项目算法和一个电子数据库，以确保在这个复杂的、多方利益相关者参与的环境中，根据患者风险和CKD阶段，为患者提供恰当、无缝衔接的护理和管理。在九个月的时间里，该项目成功筛查了所有19岁以上社区成员中的83%；发现30%的受检者患有二期或更严重的CKD。在项目参与者中，糖尿病与CKD之间存在很强的相关性。大量患者被转诊接受专科护理。该项目成功的关键在于五个利益相关者群体之间为建立合作关系所做出的努力，这五个群体分别是：原住民社区、LHIN、PRHC、当地家庭医生和专科医生。
