“团队-契约-医患合作”的糖尿病社区综合管理模式研究

"Team-Contract-Cooperation of Doctors and Patients" Model in Comprehensive Community Management of Diabetes Mellitus

目的探讨适合我国国情的"团队-契约-医患合作"的社区糖尿病综合管理模式的有效性、可行性。方法将广州市黄埔区南岗街所辖五社区(南岗、荔联、厦园、穗东、沙步)的400例自愿接受规范化管理的糖尿病患者随机分为对照组200例、干预组200例。对照组按目前日常生活模式,不进行强化干预管理;干预组由管理团队与患者及其家属签约后进行饮食、药物、运动、心理、中西药物结合治疗等方面的强化干预管理。比较两组患者在项目实施1年后的糖尿病知识、社区管理评分及血糖控制等方面的变化。结果干预后,干预组较对照组在生活质量、糖尿病知识、社区管理各项评分等方面均有明显提升,差异有统计学意义(P<0.05);血糖等各种代谢指标明显改善,差异有统计学意义(P<0.05)。结论 "团队-契约-医患合作"的社区糖尿病综合管理模式在改善糖尿病患者的糖尿病知识、提高血糖控制率、提高生命质量等方面效果显著,值得推广应用。

Objective To study the effectiveness and feasibility of ＂Team-Contract-Cooperation-Between-Doctors-and-Patients＂ model in comprehensive community management of diabetes mellitus,which is suitable for the condition of China.Methods Totally 400 diabetic patients from five communities in Huangpu District of Guangzhou City,who voluntarily accepted the standardized management,were randomly divided as control and intervention groups,with 200 in each.The patients in the control group underwent their original daily life,with no strengthened intervention management;while those in the intervention group were given strengthened intervention management on the basis of a signed contract between the management team and the patients and their family member,including management of diet,medication,exercise,psychology,and combined therapy of Chinese medicine and western medicines.One year after the management,the changes of diabetic knowledge and community management scores,and blood glucose control of the two groups were compared.Results Compared with the control group,after the management,the quality of life,diabetic knowledge,scores of various items of community management increased significantly in the intervention group（P〈0.05）;and such metabolic indicators as blood sugar were improved significantly（P〈0.05）.Conclusion This comprehensive community management of diabetes mellitus,＂Team-Contract-Cooperation-Between-Doctors-and-Patients＂ model,has a great effect in improving diabetes knowledge,increasing rate of blood sugar control,and improving quality of life.It is worth popularizing.