实施糖尿病社区管理与综合干预对血糖控制效果的评价

The Evaluation of the Effect of Blood Sugar Control through Adopting Systemic Management and Intervention to the Diabetic Patients

目的评价社区糖尿病患者管理和综合干预对血糖控制效果,为倡导社区糖尿病防治工作提供科学依据和经验。方法天津市红桥区某社区卫生服务中心登记在册的经过二级及以上医疗机构确诊的非住院的糖尿病患者376人,进行为期1年系统的综合干预,除对糖尿病患者及家属进行健康教育外,对目标人群建立健康管理档案,采取用药、膳食及体力活动指导等措施。在基线调查的基础上,分别在间隔6个月的干预中期和干预后期进行免费的体重、身高、腰围、血压等体格检查和血糖、尿常规检测。结果干预后血糖控制率较干预前均有提高(P<0.01);且干预后第一次随访的空腹血糖[(7.68±2.29)mmol/Lvs(9.20±2.58)mmol/L]和餐后2h血糖[(11.87±4.33)mmol/Lvs(13.04±4.85)mmol/L]水平较干预前均有下降(P<0.01);第二次随访比第一次随访空腹和餐后2h血糖水平下降,但差别无统计学意义。结论实行以社区为基础的糖尿病患者管理与综合干预,对糖尿病患者的血糖控制效果较好。

Objective To evaluate the effect of community management and integrated intervention on the type 2 diabetic patients in community. Methods 376 outpatients who were made a definite diagnosis by grade 2 and above hospital and registered in community health service center were enrolled in this 1-year term intervention study. The intervention methods included the education to the patients and their family members, establishing healthy reeord, and the guidance of medication treatment, diet and physical exercise. In the same time, the free of charge physical examination was made for them in every 6 months, including the examination of body weight, body height, waistline, hip circumference, blood pressure and fasting blood sugar and so on. Results The control rate of blood sugar was improved, and the glucose levels of fasting blood and 2 hours postprandial blood were decreased after intervention comparing to the before intervention. Conclusion The effect of blood sugar control was satisfactory, some systemic and comprehensive intervention measures in community should be adopted.