医防合作模式对社区糖尿病患者的管理效果研究

Study on the Management Effect of Medical-preventive Cooperation Model on Diabetic Patients

目的评价医防合作模式对社区糖尿病患者的管理效果。方法参照入选标准,选取张堰镇已建档管理的糖尿病患者437例作为研究对象,在常规随访管理的基础上,构建全科医生、专科医生、公共卫生医师一体化综合防治模式,开展连续、全程、精细化管理,给予健康教育管理、生活行为管理、用药指导等一系列管理手段。管理1年后,观察患者吸烟、饮酒、体力活动、BMI、血压、血糖、血脂等指标变化以及血压、血糖、血脂控制达标率等指标。结果管理1年后,患者的体力活动达标率、收缩压、空腹血糖(FPG)、糖化血红蛋白(HbAlc)、低密度脂蛋白胆固醇(LDL-C)、高密度脂蛋白胆固醇(HDL-C)较管理前有明显改善,差异有统计学意义(P<0.05)。患者血压、血糖、血脂控制达标率较管理前有所提高,差异有统计学意义(P<0.05)。结论医防合作模式管理社区糖尿病可以适当减少患者可改变危险因素,可推广。

Objective To evaluate the management effect of medical-preventive cooperation model on diabetic patients in communin’.Methods Refenring to the selection criteria.437diabetic patients were selected as study subjects.providing integrated prevention and control management.After one year of intervention,smoking behavior,drinking behavior,physical activity deficiency rate,overweight/obesity rate,regular medication rate,standardized management rate and blood pressure control rate were compared between the two groups.Results After one year of intervention.Physical activity rate,systolic blood pressure,fasting blood glucose(FPG).glycosylated hemoglobin(HbAlc),low density lipoprotein cholesterol(LDL-C).high density lipoprotein cholesterol(HDL-C)were improved significantly compared with those before intervention(P<0.05).Smoking and drinking behavior.MBL diastolic blood pressure,total cholesterol(TC)and three acyiglycerol(TG)were not significantly improved,with no significant difference(P>0.05).Compared with those before intervention,the control rate of blood pressure.FPG.HbAlc and blood lipid was were improved significantly,the difference was statistically significant(P<0.05).Conclusion The management of community diabetes mellitus by medical-preventive cooperation model can appropriately reduce the risk factors that patients can change,and can be popularized.