厦门市“高友网、糖友网”患者的“三师共管”模式探讨及效果评价

Specialty Physician-General Practitioner-Health Manager Management for Members of Diabetes Network and Hypertension Network from Xiamen City

目的探讨厦门市"高友网、糖友网"患者的"三师共管"模式,并进一步评价其实施效果。方法于2015年7月—2016年7月,选取厦门市思明区嘉莲街道中符合高友网和糖友网入选标准的患者为研究对象,分别为845例和787例。通过"三师共管"模式对入选患者进行为期1年的精细化、全程、综合管理。比较管理前和管理1年后高友网和糖友网患者体质指数(BMI)、腰围及收缩压、舒张压、空腹血糖、总胆固醇(TC)、三酰甘油(TG)、低密度脂蛋白胆固醇(LDL-C)、高密度脂蛋白胆固醇(HDL-C)、尿微量清蛋白、糖化血红蛋白(HbA_(1c))达标率。结果管理1年后高友网患者收缩压、舒张压、TC、TG、HDL-C、尿微量清蛋白达标率高于管理前,空腹血糖达标率低于管理前,差异有统计学意义(P<0.05);管理前和管理1年后高友网患者BMI、腰围以及LDL-C达标率比较,差异无统计学意义(P>0.05)。管理1年后糖友网患者收缩压、舒张压、空腹血糖、TC、TG、LDL-C、HDL-C、尿微量清蛋白达标率高于管理前,差异有统计学意义(P<0.05);管理前和管理1年后糖友网患者BMI、腰围以及糖Hb A1c达标率比较,差异无统计学意义(P>0.05)。结论基于"三师共管"团队协作对高友网、糖友网患者的管理模式效果显著,可有效提高患者血压、血糖、血脂、尿微量清蛋白达标率,可改善高血压、糖尿病管理效果。

Objective To analyze the theoretical characteristics and performance of specialty physician-general practitioner-health manager management for members of Diabetes Network and Hypertension Network from Xiamen.Methods According to the inclusion criteria of Hypertension Network and Diabetes Network,we enrolled 845 cases of hypertension and 787 cases of diabetes from Xiamen Siming District Jialian Street from July 2015 to July 2016.All of them received 1-year intensive,full-range and comprehensive interventions codelivered by specialty physicians,general practitioners and health managers.The evaluators for this management are BMI,waist circumference,and the control rates of systolic blood pressure(SBP),diastolic blood pressure(DBP),fasting plasma glucose(FPG),total cholesterol(TC),triacylglycerol(TG),low-density lipoprotein cholesterol(LDL-C),high-density lipoprotein cholesterol(HDL-C),urine microalbumin and glycosylated hemoglobin(HbA1c)at the end of 1-year intervention.Results At the end of 1-year management,for the hypertensive participants,compared with baseline,the control rates of SBP,DBP,TC,TG,HDL-C,and urine microalbumin increased significantly but the control rate of FPG decreased obviously(P<0.05),and BMI,waistline and control rates of LDL-C changed a little(P>0.05);for the diabetic participants,compared with the baseline,the control rates for SBP,DBP,FBG,TC,TG,LDL-C,HDL-C and urine microalbumin improved significantly(P<0.05),while BMI,waistline and control rates of HbA1c changed slightly(P>0.05).Conclusion Specialty physician-general practitioner-health manager management can increase the control rates for SBP/DBP,FPG,blood fat,as well as urine microalbumin,showing its significant management effect on both hypertension and diabetes.