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Transcript of คู่มืองบกองทุน 2557 เล่ม 4
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ISBN : 978-616-7323-89-5
1: 2556
:
: 120 3 2, 3, 4
80 5 2550
10210 0 2141 4000 0 2143 9730 www.nhso.go.th
:
: 59/4 10
11140 . 0 2903 8257-9 0 2921 4587 E-mail : [email protected]
4
()
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( )
2556
2557
1
2 3 4 (
)
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1 7- 8- 9- 12- 13
2 15 - 16- 16- 17- 17- 17- 21
3 23- 24- (Chronic Care Model) 25- Secondary Prevention 29- 30
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4 35- 36- 38- 40- 40
5 41
- 42- 42
47 1 Measurement Template 48 2 Case Report Form 74
3 98
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1
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| 25578
1.
3 .. 2546-2547 4 .. 2551-2552
15 ..2552 ( 6.9) ..2547 ( 6.85) 3 28.5
15 ..2552 (21.4) ..2547 ( 22.0) 50.3 8.7
20.9 (.)
2553
1
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1 | 9
1
(Secondary Prevention) 2557 801,240,000
2.
/
2.1
2.1.1 1) (P&PBasicService) (PrimaryPrevention) (Pre-Diabetic,
Pre-Hypertension) (Early Diagnosis)
2) (P&P Area Health Service) ( ./)
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| 255710
2.1.2 /
2.1.3
(Secondary Prevention)2.1.4 (TertiaryPrevention) ( ) () (Stroke Fast Track) ( STEMI Fast Track)
2.1.5
Primary, Secondary Tertiary Prevention
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1 | 11
1
2.2
2.3 (.)
2.4
. .2.5
2.6
1
PP
DM HT COPD
()
/
DM/HT
1.HbA1C < 7%2.LDL-Chol < 100 mg%3.BP 130/80 mmHg4.Microalbumin5.Eye Exam6.Foot Exam
Pre-DMPre-HT
Secondary Prevention Tertiary Prevention
Micro Vascular ComplicationKidney Disease
Retinopathy
Storke
Storke Fast Track
Macro VascularComplication
Heart
Acute STEMI
ST Elevated EKG
Storke Alert
, EMS,IP, OP/ER
1.2.3.
1.
2.
ACS Alert
, EMS,IP, OP/ER
Macro VascularComplication
CKD Clinic
1. 2. 3. CVD4. RRT
1. CAPD2. HD3. KT
Primary Prevention
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| 255712
3.
5 .. 2556-2560
3.1 / ./
./
3.2 (Chronic
Care Model) (Case Manager) NCD Service Plan
3.3 (System Manager)
3.4
3.5
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1 | 13
1
3.6
3.7
4.
(2553-2555)
(2556-2560)
(2556-2560)
DM&HT
DM
-
50%
30%
10%
10%
10%
2%
80%
50%
30%
30%
30%
3%
90%
90%
50%
50%
50%
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2
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| 255716
1.
()
(Secondary Prevention)
2.
2.1 2.2
2.3
2
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2 | 17
2
3.
3.1
3.2
() 3.3 /
4. 4.1 /
./4.2
5.
5.1 (
) 2557 801.240 (SecondaryPrevention)
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(801.240 .) 2ndPrevention
(748 .)
1. : 2nd Prevention = 60:40
2. (NCD Board) 2.1 90% 2.2 10%
1. 2nd Prevention2. 3. M&E
(53.240 )
2 2557
5.2 Secodary Prevention (Secondary Prevention)
2557 801.240
(NCD Board) 2557 . 80:20 60:40
5.2.1 60 (Hmain OP) OP Individual Record .
. 30 ..25565.2.2 40
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2 | 19
2
2 2556
(Medical Research Network of the Consortium of Thai Medical Schools) MedResNet (Thailand) 9
1) 1.1) HbA1c 1 1.2) LDL Lipid Profile
1 1.3) Microalbuminuria 1 1.4) 1 1.5) 1 1.6) LDL Lipid Profile
1 2)
2.1) HbA1c 7%2.2) 2.3) BP 140/90 mmHg
5.3
53,240,000 .
5.3.1
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5.3.2 (System Manager)
(Case Manager)
5.3.3 (Self Monitoring) /
5.3.4
5.3.5 /
5.4 2556
2557 2556
5.4.1 80 : 20 60 : 40
5.4.2 (NCD Board) 10 3 . .
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2
5.4.3 15 9 5.2.2
6. 6.1.
. 25566.2. . .
25566.3. (NCD Board)
. 2556
6.4 2557
6.5
6.6 13
6.6.1 6.6.2
(.)
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. .
. .
.(NCD Board) . Excel File
. / /Excel File . ( E-mail )
.
10 2556
30 2556
30 2556
15 2556
31 2557
1
2
3
4
5
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( )
1.
() () (Chronic Disease Management)
3
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3 | 25
3
(Pro-active,Population-Based Approach) ()
1) 2) 3) 4) 5)
1) 2) 3) 4)
5) 6) 7) 8) 9) 10)
2. (Chronic Care Model)
Wagner Model
6
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3
: ICIC At Group Healths MacColl Institute : Does The Chronic Care Model Work
2.1 (Health Care Organization)
/
2.2 ( Clinical Information System)
// Spreadsheet Excel Database Access
Spreadsheet Database Chronic Disease Surveillance ( )
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3
Smart DM . Excel Access
(Recall) (Review)
2.3 (Decision Support) Management Protocol/Care Pathway /
/Skype Telemedicine2.4 (Delivery System Design)
Case/DiseaseManager 3-4 1
/
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2.5 (Self-Management Support)
2.6 (Community)
2.7
Management Protocol/CarePathway
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3
3. Secondary Prevention
Secondary Prevention 1) 2) / 3) ..2554 ..2555 / Cardio-
Vascular Disease (CVD), Nephropathy, Retinopathy, Neuropathy (Foot Exam) 1 2
HbA1c Lipid Profile
Lipid Profile Urine Macro Protein / Sediment
Urine Micro Albumin FBS
-
-
2
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4.
(Diabetic Retinopathy) 2.46
(Fundus) 1 (MedResNet) 3 (2553-2555)
43.2, 50.30, 55.13
10 % Secondary Prevention (NCD Board)
4.1 4.1.1
Fundus Camera 4.1.2
Moderate
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3 | 31
3
4.1.3
4.1.4 ,
4.2 4.2.1 .
Seconday Prevention 10%
(NCD Board)
4.2.2 (NCD Board) . (NCD Board)
1)
Fundus Camera
2)
3)
4)
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5) (NCD Board)
4.2.3
1) Bevacizumab /
2) (Laser Project for Diabetic Retinopathy)
3) (DRGs)
2.2.4
(Service Plan)
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3 | 33
3
4.3
4.3.1
Fundus Camera (MedResNet)
4.3.2
4.3.3 FundusCamera
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4
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Primary, Secondary Tertiary Prevention
1.
. .
1.1 (NCD Board)
1.1.1 //
4
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4
1.1.2 / . /
1.1.3 /
( .) 1.1.4
1.1.5
1.2
1.2.1 (Management Care Protocol/Care Pathway) (CPG)
1.2.2
( Chronic Care Model)1.2.3
(DR)
1.2.4 /
1.2.5 CRCN
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1.2.6 /
2.
2.1
.
2.1.1
2.1.2 Case/Care/Disease Manager
2.1.3 ()
2.1.4
UC (Hmain) 2.1.5
Secondary Prevention 2.1.6
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4
2.1.7 2.1.8
2.1.9 2.1.10
2.2
.
2.2.1 35
2.2.2
2.2.3
2.2.4 2.2.5
2.3 ./
/
2.3.1 ()35
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2.3.2 2.3.3 2.3.4
3.
3.1 .
3.2 3.3 /
4.
2
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5
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1.
5 (.. 2556-2560) . . .
1.1
1.2 1.3 OP/PP IP Individual Record1.4
1.5
1.6
2. 2.1
2.1.1 1)
(NCD Board)
5
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5 | 43
5
2) (System Manager)
3) //
4)
5)
6) Fundus Camera
7)
8)
2.1.2 1) (Case Manager)
2)
3) 4) 5) 50
6)
7) 2.1.3
1) 2)
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3)
4)
2.1.4 ./
1) () 50% 35
2)
2.2 2.2.1 HbA1c, LDL, Micro Albumin
2.2.2 Lipid, Urine Protein FBS
2.3 2.3.1 HbA1c 7%2.3.2 LDL 100 mg/dl2.3.3 BP 140/90 mmHg2.3.4 2.3.5 2.3.6
2.3.7 28 Process Indicator,
Outcome Indicator Structure Indicator TCEN (Toward Clinical Excellence Network)
1) Fast ing Blood Suga r ( 70 mg/dl 130 mg/dl)
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5
2) HbA1c 3) HbA1c 7%4)
5) Lipid Profile 6) LDL 100 mg/dl7)
130/80 mmHg8) Micro Albuminuria 9) Micro Albuminuria ACE
Inhibitor ARB10) 11) 12) 13) 14) ,
15) 1 16) 17) Diabetic Retinopathy18) Diabetic Nephropathy19) Impaired Fasting Glucose
(IFG)
1)
(SBP 140 DBP 90)2) 3)
4)
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5) 6) 7)
.
/ Secondary Prevention
2 2556 (Medical Research Network of the Consortium of Thai Medical Schools) MedResNet (Thailand) 9
1) HbA1c 1 2) LDL Lipid Profile 1 3) Microalbuminuria 1 4) 1 5) 1 6) LDL Lipid Profile 1
1) HbA1c 7%2) 3) BP 140/90 mmHg
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Measurement Template 1
1.1 Measurement Template 1 Fasting Blood Sugar
(>70 mg/dl 70 mg/dl 70 mg/dl
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1
2 HbA1c
1. HbA1c
2. HbA1c HbA1c 1
3.
4. : HbA1c 1 X 100: 1
5.
6. 1
7.
8. 1
9. 10.
N
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3 HbA1c 7%
1. HbA1c 7%
2. HbA1c 7% Hemoglobin HbA1c 7%
3.
4. : HbA1c HbA1c 7% 1 X 100 : HbA1c 1
5.
6. 1
7.
8. 1
9. 10.
- HbA1c < 6.5%- HbA1c 6.6-7 %- HbA1c 7.1-8 %- HbA1c 8.1-9 %- HbA1c >9 %
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1
4 1.
2. (Hyperglycemia) ( ) (Hypoglycemia)
3.
4. : 1 X 100: 1
5.
6. 1 7.
8. 1
9.
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5 Lipid Profile
1. Lipid Profile 2. Lipid Profile
Total Cholesterol, Triglyceride, High-densityLipoprotein (HDL) Cholesterol, Low-density Lipoprotein (LDL)Cholesterol 1
3.
4. : 1
Lipid Profile 1 X 100 : 1
5.
6. 1
7.
8. 1
9.
10. LDL
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1
6 LDL 100 mg/dl
1. LDL < 100 mg/dl2. LDL Low-density Lipoprotein
3.
4. : LDL LDL < 100 mg/dl 1 X 100: LDL 1
5.
6. 1
7.
8. 1
9.
10. (LDL) Lifestyle 3 3 (LDL)
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7 130/80 mmHg
1. 130/80 mmHg
2. 130/80 mmHg Systolic Blood Rressure< 130/mmHg Diastolic Blood Pressure < 80/mmHg
3.
4. : 130/80 mmHg 1 X 100: 1
5.
6. 1
7.
8. 1
9.
10. (DiabeticNephropathy) 120/80 mmHg 1 X 100
130/80 mmHg
LifestyleChange 3 1stVisit
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1
8 Microalbuminuria
1. Microalbuminuria 2. Microalbuminuria
Microalbuminuria 1
3. Microvascular
4. : Microalbuminuria 1 X 100
: 1
5.
6. 1
7.
8. 1 9.
10. Microalbumin Creatinine< 1.4 Creatinine
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9 Microalbuminuria ACEInhibitor ARB
1. Microalbuminuria ACE Inhibitor ARB
2. ACE Inhibitor ARB ACE (Angiotensin Receotor Blocker) Iinhibitor Microalbuminuria
3. Microvascular
4. : Microalbuminuria ACE Inhibitor ARB 1 X 100: Microalbuminuria 1
5.
6. 1
7.
8. 1
9.
10. Nonhydropyridine Microalbuminuria
Macroalbuminuria Positive ACE Inhibitor ARB
Optional Indicator N/A
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1
10
1.
2. FundusCamera 1 1
3. Microvascular
4. : 1 X 100: 1
5.
6. 1
7.
8. 1 9.
10.
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11
1. 2.
1
3.
4. : 1 X100
: 1
5.
6. 1
7.
8. 1 9.
10.
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1
12
1. 2.
(Visual Inspection) (Sensory Exam) (Pulse Exam )
3. Macro Vascular Neuropathy
4. : 1 X100: 1
5.
6. 1
7.
8. 1
9.
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13
1. 2.
(Epithelial Abrasion) (Dry Gangrene)
3. Macro Vascular Neuropathy
4. : 1 X 100
: 1
5.
6. 1
7.
8. 1 9.
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1
14
1. 2.
Amputation Auto Amputation Dry Gangrene
3.
4. : 1 X 100
: 1
5.
6. 1
7.
8. 1 9.
10.
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15 1
1. 1
2.
3.
4. : 1 1 X 100 : 1
5.
6. 1 7.
8. 1
9.
10.
1 ()
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1
16
1.
2.
3.
4. : X100: 1
5.
6. 1
7.
8. 1
9.
10.
N/A
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17 Diabetic Retinopathy
1. Diabetic Retinopathy
2. Diabetic Retinopathy Non-proliferative Diabetic Retinopathy (NPDR)
Mild NPDR Moderate NPDR Severe NPDR) Preproliferative Diabetic Retinopathy (PPDR)
Proliferative Diabetic Retinopathy (PDR)
3. 4. : Diabetic Retinopathy
1 X 100: 1
5.
6. 1
7.
8. 1
9.
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1
18 Diabetic Nephropathy
1. Diabetic Nephropathy2. Diabetic Nephropathy
(Albuminuria) (Microalbuminuria ) (Macroalbuminuria Over
Proteinuria) Microalbuminuria
(Microalbuminuria Dipstick ) 30-300 mg Albumin/24 hrs ACR(Albumin/Cretinine Ratio) 3.4 to 34.0 mg/mmol (30-300 mg/g) 2 3 6 Microalbuminuria (Dipstick ) Trace > 300 mg Albumin/24 hrs ACR > 34 mg/mmol (300 mg/g) 2 3 6
3.
4. : Diabetic Nephropathy 1 X 100 : 1
5.
6. 1
7.
8. 1
9.
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19 Impaired Fasting Glucose (IFG)
1. Impaired FastingGlucose (IFG)
2. ( 8 > 126 mg/dl ) Impaired Fasting Glucose (IFG) 8 > 100-125 mg/dl
3. IFG
4. : IFG 1 X 100: IFG
5.
6. 1
7.
8. 1
9.
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1
1.2 Measurement Template
1 < 140/90 .
1.
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2 (Follow Up)
1. (Follow up)
2. (Follow Up)
3.
4. : Follow Up) X 100:
5.
6. 1
7.
8. 1
9.
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1
3
1.
2. 1
3.
4. :
1 X 100:
5. 6. 1 7. 8. 1 9.
10. (4, 7, 9 *)1. Fasting Plasma Glucose2. Serum Total Cholesterol, HDL-C, LDL-C, Triglyceride3. Serum Creatinine4. Serum Uric Acid *5. Serum Potassium**6. Estimated Creatinine Clearance (Cockroft-Gault Formula)
Estimated Glomerular Filtration Rate (MDRD Formula)7. Hemoglobin Hematocrit *8. Urinalysis (Dipstick Test Urine Sediment)9. Electrocardiogram ** 4, 7 9
(Optional If Indicate) ** Serum Sodium
Dichlorothiazide
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4
1.
2. - Left Ventricular Hypertrophy (LVH) - Myocardial Infarction - Angina Pectoris - Coronary Revascularization
- (Congestive) Heart Failure 3.
4. : X 100:
5.
6. 1
7.
8. 1
9.
3
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1
5
1. 2.
- Ischemic Stroke - Cerebral Hemorrhage - Transient Ischemic Attack (TIA)
3.
4. : X 100:
5.
6. 1
7.
8. 1
9.
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6
1. 2.
- Estimated Glomerular Filtration Rate* (eGFR) < 60 .//1.73
.. - Microalbuminuria Positive 30-300 ./ - : Plasma Creatinine >1.5 ./.,
> 1.4 ./.
- Albuminuria > 300 ./ Proteinuria > 500 ./3.
4. : X 100:
5.
6. 1
7.
8. 1
9.
Estimated Glomerular Filtration Rate (eGFR) Cockroft-GaultFormulaCockcroft-Gault GFR = (140-age) * (Wt in kg)
* (0.85 if Female) / (72 * Cr)
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| 73
1
7
1.
2.
3.
4. :
X 100:
5.
6. 1
7.
8. 1
9.
10.
N/A
-
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| 255774
Case Report Form (CRF) 2
(MedResNet)
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| 75
2
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| 255776
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| 77
2
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| 255778
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| 79
2
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| 255780
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| 81
2
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| 255782
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| 83
2
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| 255784
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| 85
2
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| 255786
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| 87
2
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| 255788
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| 89
2
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| 255790
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| 91
2
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| 255792
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| 93
2
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| 255794
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| 95
2
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| 255796
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2
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3
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.
. 1
. 2
. 3
. 4
02-1415040
084-7510931
02-141-4211
085-485-9414
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090-197-513902-141-4151
090-1975072
053-285-355 5023
081-993-3151
055-245-111 5172
090-197-5161
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090-197-5173
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