“三二一”医联体综合管理模式对社区糖尿病患者代谢指标的影响

Influence of “321” comprehensive management mode of medical treatment alliance on metabolic indexes of diabetic patients in the community

目的 :探索上海市静安区"三二一"医联体综合管理模式对社区糖尿病患者代谢指标的影响。方法 :2012年至2016年末对641名上海曹家渡社区糖尿病患者实施"三二一"综合管理模式,平均年龄(68.98±7.33)岁,平均病程(12.57±7.06)年,平均随访时间为(2.24±2.04)年。观察管理前后空腹血糖(FPG)、餐后血糖(PPG)、糖化血红蛋白(HbA1c)、血脂水平的变化。结果 :通过"三二一"综合管理模式的管理,社区糖尿病患者的FPG、PPG、HbA1c、总胆固醇、低密度脂蛋白胆固醇水平均比管理前下降,高密度脂蛋白胆固醇水平比管理前升高,差异均有统计学意义(P <0.05)。结论 :糖尿病"三二一"综合管理模式有助于改善社区糖尿病患者代谢指标。

Objective： To explore the infuence of “321” comprehensive management mode of the medical treatment alliance on metabolic indexes of diabetic patients in Jingan District, Shanghai. Methods： From 2012 to the end of 2016, 641 patients with diabetes in Caojiadu Community, Shanghai were under the “321” comprehensive management mode, with an average age （68.98±7.33） years and an average course of disease （12.57±7.06） years. The time of follow-up was （2.24±2.04） years. The changes of fasting blood glucose（FPG）, postprandial blood glucose（PPG）, glycosylated hemoglobin（HbA1c） and blood lipid level before and after administration were observed. Results： The levels of FPG, PPG, HbA1c, total cholesterol and low density lipoprotein cholesterol in the community patients with diabetes were lower than those before the management through the management of the “321” comprehensive management mode, the level of high-density lipoprotein cholesterol was higher than that before management, and the diference was statistically signifcant（P〈0.05）. Conclusion： The “321” comprehensive management mode of diabetes helps to improve metabolic indexes of diabetes patients in Caojiadu Community.