2型糖尿病患者社区精细化管理干预的效果评价

Evaluation on the effect of community intensive management intervention on type 2 diabetes patients

目的:探讨不同干预方法对糖尿病患者的管理效果,探索社区卫生服务中心对2型糖尿病患者的优化管理模式。方法:收治纳入社区慢病管理的2型糖尿病患者300例,随机分为干预组和对照组,各150例。干预组以全科医师-内分泌专家共同参与的健康管理团队(全-专团队)对糖尿病患者进行精细化管理,对照组采用全科医生常规的糖尿病一般管理模式。结果:干预后,干预组患者对糖尿病相关知识的掌握程度及空腹血糖、餐后2 h血糖、糖化血红蛋白、甘油三酯等较干预前有明显改善(P<0.05),与对照组比较改善明显(P<0.05)。总胆固醇、低密度脂蛋白及体重指数干预后较干预前有明显改善(P<0.05)。结论:社区卫生资源联合综合医院技术优势,建立全科医生-内分泌专家团队,有利于提高全科医师的糖尿病管理能力,同时可提高患者对糖尿病相关知识的掌握程度,改善糖尿病患者血糖和糖化血红蛋白等相关代谢指标。

Objective：To explore the effect of different intervention methods on the management of diabetic patients,and explore the optimal management mode of the community health service center for patients with type 2 diabetes.Methods：300 patients with type 2 diabetes mellitus whom were enrolled in community chronic disease management.They were randomly divided into the intervention group and the control group,with 150 cases in each group.The intervention group used fine health management team participated by general practitioners and endocrinologists to fine manage diabetic patients.The control group used general general practitioner＇s general management model of diabetes.Results：After the intervention,diabetes related knowledge, fasting blood glucose,postprandial 2 h blood glucose,glycosylated hemoglobin and triglyceride in the intervention group were significantly improved than before the intervention（P〈0.05）,and also improved significantly when compared with the control group（P〈0.05）.The total cholesterol,low density lipoprotein and body mass index after intervention significantly improved compared with before the intervention（P〈0.05）.Conclusion：The community health resources combined with comprehensive hospital technology,the establishment of a specialist-general practitioner team,is conducive to the improvement of general practitioners diabetes management ability,and can improve the patients of diabetes related knowledge,improve diabetes blood glucose and glycosylated hemoglobin metabolism.