关键词: 腹膜透析；云平台；随访管理；健康管理

Abstract: Objective: To improve follow-up management of patients receiving home-based Peritoneal Dialysis (PD) through employing a follow-up management system established on cloud platform. Methods: The follow-up platform employing cloud technology for home-based PD was officially launched in September 2018, which was used for patient admission, grading management, medical follow-up, follow-up evaluation, reminding of follow-up, intervention of complications, case closure and data analysis. Results: From September 1 to December 31 of 2018, 300 PD patients were recruited in our center and received a total of 1798 times of follow-up. The average times of follow-up increased from 5.19 to 5.99 after application of the follow-up management platform, and the participation rate of patients increased by 11.5%. The completion rate of PD diary increased from 46.7% to 62.3% (χ2=13.243, P<0.001). The time to figure out and take care of complications after they occurred by full-time PD nurses decreased from 24.5 (13.3, 36.0)h to 4.5 (2, 12) h (u=481.000, P<0.001). The overall satisfaction score of the follow-up platform service evaluated by PD patients was 4.37±0.69. Conclusion: The application of home-based PD cloud follow-up management platform not only improves the satisfaction and compliance of diary records of patients, but also increases the opportunity to spot and treat complications in time and work efficiency of full-time PD nurses.

Key words: Peritoneal Dialysis; cloud platform; follow-up management; health management