北京市西城区2型糖尿病社区管理效果评价

Effect of Community Management on Type-2 Diabetic Patients in Beijing

目的评价2型糖尿病病人社区管理的效果。方法2006年对在西城区某社区站就诊的190例2型糖尿病病人建立健康档案、问卷调查及体格检查后，对病人进行社区干预1年，再次进行问卷调查及体检。结果管理后糖尿病病人空腹血糖控制理想的比例从19．6％提高到22．8％（P〈0．05），糖化血红蛋白控制理想的比例从18．5％提高到27.2％（P〈0．05）；用胰岛素治疗的比例从21．7％提高到31．5％；定期监测糖化血红蛋白、血脂、尿常规和微量白蛋白的比例均明显提高（P〈0.05）；病人生活质量得以改善。结论社区管理可明显改善2型糖尿病病人的治疗和控制状况，但是与《中国糖尿病防治指南》的要求相比仍有较大差距，如何提高社区疾病管理的水平和效果是亟待解决的重要问题。

Objective To study the effect of community management on patients with type 2 diabete mellitus（DM）. Methods One community health service station was chosen. The 190 DM patients who came to this station for the medical consultation were asked to finish a questionnaire and did physical assessment. After l year follow-up, all the cases were asked to do the questionnaire and physical assessment again. Results The proportion of the well-controlled patients＇ fasting plasma glucose, glycosylated hemoglobin and insulin treatment increased from 19.6% to 22.8% （P〈0.05）, 18.5% to 27.2 （P〈0.05） and 21.7% to 31.5% （P〈0.05） respectively. DM patients went to take their different blood test more regularly and there was also a significant increase on the control of glycosylated hemoglobin, blood lipid, urinary routine examination and urinary trace albumin（P〈0.05）.Patients＇ quality of life had improved.Conclusion The DM patients had better disease control via the community management for type-2 DM, but there is a vast gap with the requirements from the guidelines for diabetes management. How to increase the level of community disease management and its effect is a critical problem.