电话回访对农村地区糖尿病患者的延续性护理及医疗状况调查研究

Application of the continuous nursing based on telephone follow-up for diabetic patients in rural areas and the investigation research on medical service status

目的通过定期电话回访的方式对南充市周边农村地区糖尿病患者进行延续性服务,了解患者医疗状况,对患者进行健康指导。方法通过电话回访的方式,对523例农村地区糖尿病患者进行回访,回访3个月。观察回访前后患者血糖的变化、并发症的发生率及自我护理能力。结果在进行电话回访后,糖尿病患者空腹血糖(FPG)、餐后2 h血糖(P2hPG)和糖化血红蛋白(Hb A1c)均较电话回访前明显降低,差异有统计学意义(P <0. 05)。在进行电话回访后,糖尿病患者的低血糖、酮症酸中毒、足部病变和眼部病变并发症的发生率均下降,电话回访后并发症总发生率为4. 59%(24/523)低于电话回访前的15. 30%(80/523),差异有统计学意义(χ~2=33. 480,P <0. 05)。在进行电话回访后,糖尿病患者的血糖监测、血糖异常处理、遵医用药、合理饮食和适当锻炼评分均较回访前明显升高,差异有统计学意义(P <0. 05)。结论通过3个月定期的电话回访方式对农村地区糖尿病患者进行延续性服务,了解患者的医疗状况,有利于帮助糖尿病患者更好地控制血糖水平,降低并发症的发生率,提高患者自我护理能力。

Objective To provide continuous nursing based on telephone follow-up for diabetic patients in rural areas of Nanchong, in order to understand the medical service status and carry out health education. Methods A three-month follow-up by telephone was conducted to 523 di- abetic patients in rural areas of Nanchong. The change of blood glucose level, incidence of complications and self-care ability of patients were observed after follow-up. Results After three- month follow-up by telephone, there was a decreased level of fasting blood glucose, 2 h postpran- dial blood glucose and hemoglobin A1 c among patients （P 〈 0.05 ）. There was a decreased inci- dence of hypoglycemia, ketoacidosis, foot lesions and diabetic oculopathy after follow-up, the overall complication rate dropped from 15.30% （80/523）before implementation of telephone follow-up to 4.59 % （24/523） after implementation of telephone follow-up （χ2= 33. 480, P 〈 0.05 ）. Patients achieved higher scores in assessment of blood sugar monitoring, treatment on glucose ab-normalities, medication adherence, reasonable diet and suitable exercise after follow-up compared with those of patients before follow-up （P 〈 0.05）. Conclusion Based on a three-month follow-up by telephone, continuous services were conducted on diabetic patients in rural areas and patients＇medical status were continuously monitored. The continuous nursing based on telephone follow-up is effective for diabetic patients to control blood glucose level and reduce the risk of dia- betic complications.