社区糖尿病患者进行社区-医院一体化管理的应用

Management application of community-integrated hospital for community diabetes

目的：研究社区糖尿病患者运用社区一医院糖尿病一体化信息系统进行管理的应用，观察其效用，并为进一步完善糖尿病管理工作提出有效建议。方法从本社区居民电子健康信息档案数据库中选取2014年1月～2015年1月期间糖尿病管理项目中全部管理对象的基本信息，以及这些对象的所有随访信息，分析阂行区糖尿病人群特征以及糖尿病管理的现况、效果及影响因素。结果分析发现年龄增长（＞50岁）、接受群组随访、上门随访和进行重度体育锻炼为2型糖尿病患者血糖控制达标的危险因素；病程延长（超过7年）、超重和肥胖不利于2型糖尿病患者血糖控制达标。病程超过1年、接受群组随访、不使用药物治疗有利于糖耐量异常患者向糖代谢正常转化。结论对社区糖尿病患者运用社区一医院糖尿病一体化信息系统进行管理，对疾病的控制有良好的效果，有助于强化了社区医疗机构在糖尿病筛查中的作用。

Objective To study management application effect of Community-Integrated Hospital for Community diabetes,to give good advice for improving furtherly management of diabetes soil. Methods Diabetes management program from January 2014 to January 2015 were selected in the basic information of all managed objects,and status of people with diabetes and diabetes management features,effects and influencing factorsthey were analyzed in Minhang District diabetic. Results Age （over 50 years）,accept the group follow-up,follow-up and carried home,severe physical exercise were risk factors for patients with 2type diabetes blood sugar control standard;Duration of more than one year,to accept the group follow-up,do not use drug were beneficial for tolerance to normalthe. Conclusion Community-a community hospital in diabetic patients with diabetes to manage the integration of information systems,the control of the disease has a good effect,helps to strengthen the role of community health care institutions in diabetes screening.