TITLE:
Development and Evaluation of Chronic Disease Care Management System in High-Altitude Regions: Evidence from Nyingchi, Xizang
AUTHORS:
Ying Wu, Lijuan Dong, Weijie Zhu, Hongying Baima, Lihong Liu
KEYWORDS:
Chronic Disease, Nursing Management, High-Altitude Regions, Information System, Nyingchi, Telemedicine, Nursing Consultation
JOURNAL NAME:
Journal of Biosciences and Medicines,
Vol.13 No.8,
August
20,
2025
ABSTRACT: Objective: To evaluate the development and implementation of a chronic disease care management system in high-altitude regions, aiming to address challenges including geographical barriers, limited healthcare resources, and improving primary care quality. Methods: A three-tier chronic disease management network (township health centers, county hospitals, municipal tertiary hospital) was established in Nyingchi, Xizang. This system incorporated multifunctional health kiosks, teleconsultation platforms, and electronic health records management. The intervention covered prevalent chronic conditions (hyperglycemia, diabetes mellitus, coronary artery disease, and Kashin-Beck disease) through coordinated data collection, remote nursing consultation, and targeted interventions. Specialized nursing clinics (e.g., Diabetes Care Clinic, PIVC Care and Consultation Clinic) were introduced in the system. Improvements in primary care capacity, health record quality, and care efficiency were assessed post-implementation. Results: Following system implementation across 271 primary care institutions, the chronic disease management system now covered 114 facilities, representing a 42% increase in coverage. We also observed: significant improvement in health record completeness (rising from 68% to 91%); reduced teleconsultation response time (within 4 hours); and a 37% decrease in referral rates for acute chronic disease exacerbations. Conclusion: This integrated chronic disease management system effectively addresses healthcare disparities in high-altitude regions by optimizing resource allocation through digital health solutions, demonstrating particular utility for remote, medically underserved settings.