社区家庭医生糖尿病链式分层管理的效果评价

Effect Assessment on the Hierarchical Chain Management Model of Type 2 Diabetes by General Practitioner

目的探索社区家庭医生健康管理下2型糖尿病链式分层管理模式,并进行效果评价。方法以上海市徐汇区凌云街道社区卫生服务中心的392例已进行家庭医生签约的2型糖尿病患者为对象,进行链式分层管理并完成随访研究。结果糖尿病患者管理1年后和基线比较,空腹血糖、餐后2 h血糖、糖化血红蛋白、甘油三脂、低密度脂蛋白胆回醇、收缩压和舒张压明显下降,分别由(8.68±3.47)mmol/L、(11.07±4.35)mmol/L、(8.18±1.99)mmol/L、(2.69±2.68)mmol/L、(3.16±0.88)mmol/L、(130.70±14.78)mmHg和(77.72±7.44)mmHg下降至(7.25±2.46)mmol/L、(9.54±3.19)mmol/L、(7.16±1.41)mmol/L、(2.27±2.23)mmol/L、(2.95±0.84)mmol/L、(127.99±11.01)mmHg和(76.65±6.30)mmHg,差异有统计学意义(P<0.05);空腹血糖、餐后2 h血糖、糖化血红蛋白、甘油三脂、低密度脂蛋白胆固醇和血压达标率明显提高,由管理前的37.8%(148/392)、49.0%(192/392)、31.6%(123/392)、40.8%(160/392)、24.5%(96/392)、35.7%(140/392)和31.6%(124/392)提高到55.1%(216/392)、61.2%(240/392)、53.1%(208/392)、52.0%(2041392)、37.8%(148/392)、43.9%(172/392)及39.8%(156/392),差异有统计学意义(P<0.05)。结论在社区实行家庭医生责任制并开展糖尿病链式分层管理可行有效、可操作性强,可继续深化推广。

OBJECTIVE To explore the hierarchical chain management model of type 2 diabetes by general practitioner and determine its evaluation in community. METHOD Based on the hierarchical chain management of type 2 diabetes signed with general practitio- ner in LingYun community, 392 cases had been involved in this study. RESULTS Compared with the baseline before management, fasting blood glucose（FBG）, 2 h postprandial glucose（2 hPBG）, glycosylated hemoglobin（HbAlc）, triglycerides, low-density lipoprotein cholesterol（LDL-C）, systolic blood pressure（SBP）, diastolic blood pressure（DBP） of the diabetes after lyear＇s management declined [（8.68±3.47）mmol/L, （11.07±4.35）mmol/L, （8.18±1.99）mmol/L, （2.69±2.68）mmol/L, （3.16±0.88）mmol/L, （130.70±14.78）mmHg, （77.72 ± 7.44）mmHg vs. （7.25± 2.46）mmol/L, （9.54 ± 3.19）mmol/L, （7.16 ± 1.41）mmol/L, （2.27 ± 2.23）mmol/L, （2.95 ± 0.84）mmol/L, （127.99±11.01）mmHg, （76.65±6.30）mmHg], and the differences were statistically significant（P〈0.05）; control rate of FBG, 2 hPBG, HbAlc, triglycerides, LDL-C, SBP, DBP had been improved significantly [37.8% （148/ 392）, 49.0% （192/392）, 31.6% （123/392）, 40.8% （160/392）, 24.5% （96/392）, 35.7% （140/392）, 31.6% （124/392） vs. 55.1% （216/392）, 61.2% （240/392）, 53.1% （208/392）, 52.0%（204/392）, 37.8%（148/392）, 43.9%（172/392）, 39.8%（156/392）] （P〈O.05）. CONCLUSION Responsibility system of family docto and hierarchical chain management of diabetes in the community is effective, feasible and operational. It can continue to deepen promotion.