家庭医生制度在糖尿病管理中的路径及效果评价

The management path and the evaluation of the effect in patients with diabetes under the family doctor responsibility system

目的 :探索家庭医生制度在糖尿病管理中的路径,并对其效果进行评价。方法 :通过对某社区卫生服务中心管理的糖尿病患者的建卡及随访资料的数据统计,反映该中心在实施家庭医生制度糖尿病管理路径前后的各项指标变化并对结果进行分析评价。结果 :社区家庭医生服务实施后,通过其有效规范的管理路径,某社区的糖尿病患者的认知率、管理率、登记率、随访率、规范管理率、服药依从率等各项指标都有了明显的提高,实施后患者的空腹血糖、餐后2h血糖及体质指数都有明显下降(P<0.05)。结论:家庭医生制度下糖尿病的管理路径能有效提高糖尿病患者的管理效果。

Objective：To explore the management path in patients with diabetes and to evaluate the effect under the family doctor responsibility system. Methods：Statistics from the date of the diabetics who had been managed in one community health service center were analyzed and the change of the index after the family doctor responsibility system was reflected. Results：After performing community-based family doctor responsibility system and using the effective management path,the index of cognition rate,management rate,registration rate,follow-up rate,normalized management rate,complete drug use adherence rate significantly improved in patient with diabetes in the community. The fasting plasma glucose level,2h-postprandial plasma glucose level and body mass index all decreased（P〈0.05）. Conclusion：The management of the diabetics can be much more effective through performing the path with family doctor responsibility system.