依托医联体开展社区糖尿病患者分层护理管理的效果

Effect of hierarchical nursing management of diabetic patients in community based on medical combo system

目的评价依托区域医联体对社区糖尿病患者进行分层护理管理的效果,探索适合中国国情的糖尿病社区护理分层管理模式。方法于2014年1月—2015年1月选取上海市普陀区西部医联体范围内4个社区卫生服务中心登记在册的384例糖尿病患者,用抽签法分为对照组和观察组各192例,观察组再根据评估结果分为普通亚组和高危亚组,进行分层管理;比较实施干预1年内社区糖尿病患者的健康教育依从性、空腹血糖、糖化血红蛋白、住院率及严重并发症发生率等的差异。结果实施分层管理1年后,观察组患者空腹血糖及糖化血红蛋白均显著低于对照组(P<0.05),且观察组患者1年内肾脏病变、眼部病变、足部病变、总并发症发生率及入院率均低于对照组(P<0.05);高危亚组患者服药、饮食控制、合理运动、血糖监测、足部护理的依从性均明显优于干预前(P<0.05)。结论依托医联体开展的社区糖尿病分层护理管理模式,能够充分利用有限的医疗资源做好社区管理,从而对提高患者的生活质量、控制糖尿病进程起到积极作用。

Objective To evaluate the effect of hierarchical nursing management of diabetic patients in community based on medical combo system, and to explore the suitable management model in China. Methods From January 2014 to January 2015, 384 diabetic patients who registered in the community health services centers of Zhenru, Taopu, Caoyang, Changzheng in Putuo District were selected. They were equally divided into the control group and observation group. And the patients in the observation group were re-divided into the normal subgroup and high-risk subgroup. The differences in medication compliance, fasting blood glucose, glyeosylated hemoglobin, admission rate, incidence of severe complications were compared. Results After one-year intervention, the levels of fasting blood glucose and glycosylated hemoglobin in the observation group were significantly lower than those in the control group （ P 〈 0.05 ）. So were the incidences of renal lesions, ocular lesions, foot lesions, total incidence of complications, and admission rate （P 〈 0.05 ）. The high-risk subgroup had better compliance in medication, dietary management, reasonable exercises, blood glucose monitoring, and foot care compared with pre-intervention （ P 〈 0.05 ）. Conclusion The hierarchical nursing management of diabetic patients in community based on medical combo system could make full use of the limited medical resources. It could also improve the quality of life of patients, and play a positive role in the control of diabetes.