Chronic disease management ATT

Chronic disease management ATT is essentially a set of ground-level chronic disease management framework with "Assessment-Tracking-Intervention" as the core cycle. The core advantage is that it breaks away from the past emphasis on medical treatment and neglect of follow-up. , or the misunderstanding of choosing between focusing on services and neglecting clinical practice. According to the 2023 pilot data of the National Public Health System, the ATT model, which has been implemented in community health service centers in 12 provinces and cities in China, has increased the blood pressure and blood glucose compliance rates of patients with hypertension and diabetes by an average of 27.3%.

Last year, I stayed at the Community Health Service Center of Chaoming Street, Xiacheng District, Hangzhou for three months, just in time to catch up with their first batch of pilot ATT models. I met Aunt Zhang, a 62-year-old type 2 diabetic patient. Her blood sugar had been between 9-11mmol/L for six months in a row. Her family doctor said that she told her to avoid food and test her blood sugar regularly, but she forgot about it when she turned around.

When it comes to the first step of ATT evaluation, there are actually two different voices in the industry. Most doctors with clinical background insist that the evaluation should be based on biochemical indicators as the core, and the rest of the living habits and family conditions are auxiliary references and should not be given too much weight, otherwise it will easily deviate from the essence of medical treatment. ； However, most practitioners with a public health background disagree and feel that at least 40% of the weight should be allocated to non-clinical indicators. For example, when Aunt Zhang was evaluated using the ATT framework for the first time, in addition to measuring her fasting blood sugar and glycosylated hemoglobin, we also recorded that she danced for an hour a day, ate soy sauce duck twice a week, lived alone, and her children came only once every half month. The implementation of subsequent intervention plans was all supported by this "non-clinical" information.

Once the evaluation is done, if the data lies in the file and sleeps, it will be in vain. In the past, many chronic diseases could not be managed, and they were stuck here - the patient went home, and the doctors and nurses had no idea whether he had taken his medicine on time or had his blood sugar tested.

Now ATT's tracking process has taken two completely different paths. For young patients with chronic diseases under the age of 45, most of them use hardware solutions: smart blood pressure monitors and dynamic blood glucose meters are bound to mobile APPs, and the data are automatically synchronized to the backend of the family doctor. If the data is abnormal for three consecutive days, the system will automatically send a reminder, without the patient having to upload it manually, which saves a lot of trouble. ； But for elderly people like Aunt Zhang who don’t know how to use smartphones, we had to adopt a soft-service approach: We changed her small program into a large-print version. After measuring her blood sugar, just click on it. Once she uploads it, she will be given 10 points. Points will also be given for synchronizing the steps of square dancing. If she saves enough, she can exchange for daily necessities such as eggs and rice. Don’t mention it, she only tested her blood sugar once half a month ago. After three months of the pilot, she tested it at least four times a week, and her compliance has tripled.

Once the data catches up, intervention can be precise. Aunt Zhang's doctor always told her before that "soy duck is high in sugar and salt and must not be eaten." She always bought it secretly and couldn't stop her. Later, based on her evaluation results, our nutritionist gave a "compromise" plan: you can eat sauced duck once a week, up to 2 taels each time, reduce the staple food by 1/3 on the day you eat it, and dance in the square for 20 minutes more, without affecting blood sugar at all.

When it comes to the scale of intervention, there has been ongoing debate within the industry. One group believes that clinical guidelines must be followed strictly and no compromise can be given, otherwise no one will be held responsible if something goes wrong with the patient. ； The other group believes that "flexible adaptation" is required. As long as it is within the safety threshold, enough living space must be left for the patient - you can't let the elderly give up all their lifelong hobbies in order to control blood sugar, right? It really forces people to obey the good and the bad, which makes it worse. Aunt Zhang's current fasting blood sugar is stable between 6.5-7mmol/L, which is the best example.

I have been engaged in chronic disease management for almost three years. To be honest, ATT is not a new black technology. To put it bluntly, it is the evaluation, follow-up, and medication prescribing that everyone had done in pieces before, and put it into a cycle that can be turned around. Of course, there are many problems now. For example, many underdeveloped areas cannot keep up with informatization. Assessment data cannot be directly synchronized to the tracking system and must be entered manually, which is very inefficient. ； There is also a shortage of grassroots medical staff. A family doctor has to take care of hundreds of patients with chronic diseases. It is really too busy to chase data one by one.

Last month I went to Chaoming Street again, and I happened to see Aunt Zhang coming out of the vegetable market carrying half a sauced duck. She waved the chronic disease score card at me from a distance and said that the glycosylated hemoglobin measured last week was only 6.2. If I accumulated enough points this month, I could buy a 10-pound bag of rice next week.

You see, no matter how good the management framework is, it will eventually be considered useful if it is used in ordinary people’s daily meals, vegetables, and fireworks.