全科—专科联合管理新模式在城市社区糖尿病管理中的实践与探讨

Exploration and practice of new integrated management of general practitioner and specialist on diabetes management in community

目的建立全科—专科联合管理的新模式,研究其对糖尿病患者的管理效果,以探讨更为合理的城市社区糖尿病管理模式。方法从中心已建档案的Ⅱ型糖尿病患者中随机抽取172例,按照患者自愿原则分成研究组78例和对照组94例,对照组采用传统社区管理模式;研究组在此基础上由全科—专科医师进行联合管理、开展群体性健康教育和患者的自我管理。干预随访两年后,比较两组血糖指标及糖尿病知识知晓率、健康相关行为改善率,居民就诊满意率有无差别。结果管理前两组血糖指标比较差异无统计学意义(P>0.05)。随访两年后,研究组的空腹血糖和糖化血红蛋白(HbA1c)水平低于对照组,空腹血糖和HbA1c达标率明显高于对照组,差异均有统计学意义(P<0.05)。患者糖尿病知识知晓率、健康相关行为改善率,居民就诊满意率均较对照组有明显提高,差异均有统计学意义(P<0.01)。结论在城市社区应用全科—专科联合管理糖尿病的新模式,更有利于患者实现血糖控制,增加健康行为和提升社区诊治的依从性等作用,是一种提倡与推广的新的有效可行的糖尿病管理模式。

Objective To evaluate the effect on the management on the patients with diabetes by setting a new mode of integrated management of general practitioner and specialist,to explore the more rational mode of community-level diabetes management. Methods 172 subjects with type Ⅱ diabetes filed in Datang community health service center were randomly selected as the study subjects,who were divided into experimental group with 78 subjects and control group with 94 subjects on a voluntary basis. The control group was adopted the traditional community management model,while besides that,the experimental group was treated by general practitioner jointed with specialist physician,given group education and conducted selfmanagement. After two-years of follow-up,the two groups were compared on blood glucose-related body indexes,awareness rate of diabetes,the improvement of health-related behavior and medical satisfaction. Results Before the treatment,there was no statistical difference on blood glucose-related indexes between two groups（ P〉0. 05）. After two years of follow-up,compared with the control group,the fasting blood glucose and glycosylated hemoglobin（ HBAlc） was lower,while the awareness rate of diabetes,the improvement of health-related behavior and medical satisfaction was apparently higher than that in the control group,and the difference was statistically significant（ P〈0. 01）. Conclusion It could be benifacial for diabetes to control blood glucose,promote health-related behavior and elevate treatment compliance,the integrated management of general practitioner and specialist could be an effective and feasible new mode management for diabetes,which deserving advocation and expansion in community.