将糖尿病护理从医院分散到马拉维的初级卫生保健中心。
Decentralising diabetes care from hospitals to primary health care centres in Malawi.
机构信息
Dignitas International, Zomba, Malawi.
Department of Medicine, University of Malawi College of Medicine, Blantyre, Malawi/Kamuzu University of Health Sciences.
出版信息
Malawi Med J. 2021 Sep;33(3):159-168. doi: 10.4314/mmj.v33i3.3.
BACKGROUND
Non-communicable diseases (NCDs) such as diabetes and hypertension have become a prominent public health concern in Malawi, where health care services for NCDs are generally restricted to urban centres and district hospitals, while the vast majority of Malawians live in rural settings. Whether similar quality of diabetes care can be delivered at health centres compared to hospitals is not known.
METHODS
We implemented a pilot project of decentralized diabetes care at eight health centres in four districts in Malawi. We described differences between district hospitals and rural health centres in terms of patient characteristics, diabetes complications, cardiovascular risk factors, and aspects of the quality of care and used multivariate logistic regression to explore factors associated with adequate diabetes and blood pressure control.
RESULTS
By March 2019, 1339 patients with diabetes were registered of whom 286 (21%) received care at peripheral health centres. The median duration of care of patients in the diabetes clinics during the study period was 8.8 months. Overall, HIV testing coverage was 93.6%, blood pressure was recorded in 92.4%; 68.5% underwent foot examination of whom 35.0% had diabetic complications; 30.1% underwent fundoscopy of whom 15.6% had signs of diabetic retinopathy. No significant differences in coverage of testing for diabetes complications were observed between health facility types. Neither did we find significant differences in retention in care (72.1 vs. 77.6%; p=0.06), adequate diabetes control (35.0% vs. 37.8%; p=0.41) and adequate blood pressure control (51.3% vs. 49.8%; p=0.66) between hospitals and health centres. In multivariate analysis, male sex was associated with adequate diabetes control, while lower age and normal body mass index were associated with adequate blood pressure control; health facility type was not associated with either.
CONCLUSION
Quality of care did not appear to differ between hospitals and health centres, but was insufficient at both levels.
背景
非传染性疾病（NCDs）如糖尿病和高血压已成为马拉维突出的公共卫生问题，在该国，NCD 医疗服务通常仅限于城市中心和地区医院，而绝大多数马拉维人居住在农村地区。目前尚不清楚在卫生中心提供的糖尿病护理质量是否与医院相当。
方法
我们在马拉维四个地区的八个卫生中心实施了一项去中心化糖尿病护理试点项目。我们比较了地区医院和农村卫生中心在患者特征、糖尿病并发症、心血管风险因素以及护理质量方面的差异，并使用多变量逻辑回归来探讨与糖尿病和血压控制达标相关的因素。
结果
截至 2019 年 3 月，共有 1339 名糖尿病患者登记，其中 286 名（21%）在基层卫生中心接受治疗。在研究期间，糖尿病诊所的患者中位护理时间为 8.8 个月。总体而言，HIV 检测覆盖率为 93.6%，记录血压的比例为 92.4%；68.5%进行了足部检查，其中 35.0%有糖尿病并发症；30.1%进行了眼底检查，其中 15.6%有糖尿病视网膜病变迹象。在卫生机构类型之间，检测糖尿病并发症的覆盖情况没有显著差异。我们也没有发现医疗机构类型与保留治疗（72.1%比 77.6%；p=0.06）、糖尿病控制达标（35.0%比 37.8%；p=0.41）和血压控制达标（51.3%比 49.8%；p=0.66）之间存在显著差异。在多变量分析中，男性与糖尿病控制达标相关，而年龄较小和正常体重指数与血压控制达标相关；医疗机构类型与两者均无关联。
结论
医院和卫生中心的护理质量似乎没有差异，但在两个层面上都不充分。
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