社区-医院一体化糖尿病管理模式的效果分析

Study on the community-hospital integrated diabetes management

目的了解构建社区-医院一体化糖尿病管理新模式的效果。方法制定社区-医院一体化糖尿病管理和操作指南,实施干预,收集干预前后患者患病及治疗信息,进行效果评价。结果经过3年的管理,患者空腹血糖值范围在4.4~6.2 mmol/L的比例增高,空腹血糖值≥7.0 mmol/L的比例降低（P〈0.05）。患者空腹血糖均值显著降低,平均降低了1.35 mmol/L。患者并发症发生率降低,门诊及住院服务利用率增高,综合医院候诊时间缩短（P〈0.05）。结论社区-医院一体化糖尿病管理模式可以有效控制患者病情,值得推广。

Objective To study and constitute the new community-hospital integrated diabetes management.Methods Community-hospital integrated intervention was given to patients with type 2 diabetes and the data was analyzed and evaluated. Results After 3-year management the proportion of FPG range between 4.4-6.2 mmol/L increased,while FPG≥7.0 mmol/L decreased（P0.05）.The average FPG significantly decreased from 7.75 mmol/L to 6.40 mmol/L.The incidence rate of complications and the waiting time reduced while the health care utilization was raised（P0.05）.Conclusion The model of community-hospital integrated diabetes management was effective in improving diabetes condition and recommended for dissemination.