南京市华侨路社区糖尿病患者“医院社区一体化管理”效果评价

Effect evaluation on hospital-community integrated management for diabetes patients in Huaqiaolu community of Nanjing

目的探讨医院-社区一体化模式对2型糖尿病社区的管理效果。方法在社区医院建立糖尿病健康小屋,实施医院-社区一体化糖尿病管理,对建档的2型糖尿病患者按照"分阶段糖尿病达标管理"理念,进行为期24个月随访、追踪管理效果。结果 325例患者糖化血红蛋白(HbALc)、空腹血糖(FBG)、餐后2h血糖、血压、血脂水平,均较管理前有所下降。管理24月后,HbAlc达标率由56.4%提高至78.1%,FBG达标率由59.6%提高至79.4%,餐后2h血糖达标率由59.0%提高至73.2%,血压达标率由71.5%提高至90.6%,差异均有统计学意义(P<0.05)。结论社区建立糖尿病健康小屋,通过医院-社区一体化管理,可以使糖尿病患者的血糖、血压控制情况得到明显改善。

Objective To investigate the effect of diabetes patients management by hospital-community integrated model. Methods Self-service Health Room was set up in the community service center and hospital-community integrated management was conducted for diabetes patients. Totally 325 type 2 diabetic patients were recruited and followed up for 24 months accord- ing to the concept of standard diabetes management in stages. The effect of intervention was also evaluated. Results Prior to the intervention, glycosylated hemoglobin, fasting blood-glucose, 2-hour post-meal blood glucose, blood pressure and blood lipid were reduced on meeting the standard. After 24 months management, rates of meeting the standard of HbAlc increased from 56.4% to 78.1%, FBG increased from 59.6% to 79.4%, 2-hour post-meal blood glucose increased from 59.0% to 79. 4% and blood pressure increased from 71.5% to 90.6%. All differences were shown with statistical significance （P〈0.05）. Conclusion Self-service Health Room in the community service center and hospital-community integrated management are helpful to improve the blood glucose and blood pressure of diabetes patients obviously.