社区综合干预防治糖尿病的研究和实践

目的:评价社区综合干预对糖尿病防治的效果和意义,以及探索综合防治的社区管理模式。方法:对所辖社区60例糖尿病患者采用以非药物治疗为主的综合干预手段,以"能量平衡,有效运动,量化管理"为核心,实施健康教育、饮食、运动量化管理,用药指导和定期随访监测,运用用社区慢病管理软件,分级分类网格化管理1年。结果:干预后60例在糖尿病相关知识知晓率,空腹血糖(FBG)、餐后2小时血糖(2hPG),血糖控制率,运动参与率比干预前有明显的改善;服用糖尿病药物的月平均费用比干预前有明显的减少,差异有统计学意义。结论:社区综合干预防治糖尿病有较好的效果,提高了患者的生存质量,减轻了个人和家庭乃至社会的经济负担,社区综合防治的管理模式值得积极探讨和推广。

Objective：Evaluating the effects of the community comprehensive intervention on diabetes prevention and treatment,and exploring its management model.Method：60 diabetic patients in the community were adopt a non-drug treatment-based,integrated intervention,of which＂energy balance,an effective campaign,quantitative management＂as the core.The health education,diet,exercise quantitative management,medication guidance and regular follow-up monitoring tool were implemented with use of community chronic disease management software and hierarchical classification grid management for 1 year.Results：60 patients have made significant improvements in diabetes-related knowledge,awareness,fasting blood glucose （FBG）,postprandial 2h plasma glucose （2hPG） and blood glucose control rates through the intervention.Less average monthly cost of diabetes drugs was achieved after the intervention and the difference was statistically significant.Conclusion：Community intervention of diabetes prevention and control has achieved ideal results,with the improving of patient＇s quality of life both individual and family as well as reduction of social and economic burden.This prevention and control management model worth active exploring and promotion.