基于家庭医生责任制的社区糖尿病患者预约积分制管理模式初探

Preliminary study of community diabetic appointment points system management mode based on family doctor responsibility system

目的:探索在家庭医生签约管理的基础上通过预约积分制吸引糖尿病患者主动参与管理的模式。方法:在2015年10月1日至2017年9月30日的3年间对社区6个家庭医生工作站所有在册管理的糖尿病患者实行预约积分制管理,评估糖尿病患者的服药依从性和血糖控制情况。结果:在家庭医生预约积分制管理后1年和2年的预约积分管理的糖尿病人数分别为1 043人(23.8%)和2 527人(47.1%);在家庭医生预约积分制管理前、管理后1年和2年在管糖尿病患者的规范随访率分别为69.92%、83.12%和87.56%,在管糖尿病患者血糖控制率分别为45.4%、59.5%和64.0%,患者的服药依从性和健康教育参与率都有明显提高,差异均有统计学意义(P<0.05)。结论:以提升患者主动参与意识为手段的预约积分制管理模式可改善社区糖尿病患者规范管理率和控制率,提高社区糖尿病管理质量。

Objective: To explore the mode of attracting diabetic patients to participate actively in the management through appointment points system management mode on the basis of contract management of family doctors. Methods: During the three-year period from October 1, 2015 to September 30, 2017, all registered diabetic patients in six family doctor workstations in the community were managed by appointment points system management mode, and the medication compliance and blood sugar control of diabetic patients were evaluated. Results: The numbers of diabetes patients managed by the family doctors with appointment points system after one-year and two-year were 1 043 (23.8%) and 2 527 (47.1%), respectively;the standardized follow-up rates of patients with diabetes mellitus before the family doctor's appointment points system management, 1 year and 2 years after management were 69.92%, 83.12% and 87.56%, respectively, the glycemic control rates in patients with diabetes in the management were 45.4%, 59.5% and 64.0%, respectively, medication compliance and health education participation rate of the patients were significantly improved, and the differences were statistically significant(P<0.05). Conclusion: The appointment points system management mode, which enhances patients' active participation and consciousness as a means, can improve the standard management rate and control rate of community diabetes patients, and improve the quality of diabetes management in the community.