分级诊疗及家庭医师团队模式下社区糖尿病管理研究

Management for diabetes mellitus in community under the model of graded diagnosis, treatment and team of family physicians

目的探究分级诊疗及家庭医师团队模式下社区糖尿病管理效果。方法选取164例糖尿病患者作为研究对象,其中接受分级诊疗及家庭医师团队模式进行管理的89例糖尿病患者作为观察组,按照传统模式管理的75例为对照组。比较两组患者依从性、血糖、血脂、血压及健康知识知晓情况。结果干预后3个月、干预后1年,观察组患者的依从性得分分别为(6.35±2.05)分和(7.19±2.54)分,均高于对照组(5.39±1.17)分和(5.87±1.21)分,差异有统计学意义(P<0.05)。干预后1年,观察组患者的空腹血糖(FPG)、糖化血红蛋白(HbA1c)及餐后两小时血糖(2hPG)、总胆固醇(TC)、低密度脂蛋白胆固醇(LDL-C)、甘油三酯(TG)、收缩压(SBP)及舒张压(DBP)水平分别为(8.71±1.94)mmol/L,(7.52±1.58)%,(8.84±2.32)mmol/L,(4.71±1.74)mmol/L,(2.59±0.91)mmol/L,(1.69±0.80)mmol/L,(136±22)mmHg,(75±6)mmHg,均低于对照组(9.48±2.07)mmol/L,(8.35±1.97)%,(9.69±2.88)mmol/L,(5.29±1.86)mmol/L,(3.05±0.97)mmol/L,(2.06±0.91)mmol/L,(145±26)mmHg,(81±9)mmHg,差异有统计学意义(P<0.05)。干预后,观察组患者的健康知识知晓率、合理服药率、定期自我监测血糖率、血糖达标率及血脂达标率均高于对照组(69.66%vs 53.33%,77.53%vs 62.67%,73.03%vs 53.33%,69.66%vs 53.33%,39.33 vs 22.66%,P均<0.05),血压达标率则差异无统计学意义(30.34%vs.29.33%,P>0.05)。结论分级诊疗及家庭医师团队模式对社区糖尿病的管理效果更好,可有效提高患者的疾病知识的知晓率,促进其健康行为建立与维持,并对血糖、血脂及血压进行有效控制。

Objective To observe the effect of management for community diabetes under the model of graded diagnosis, treatment and team of family doctors. Methods A total of 164 patients with diabetes mellitus were recruited and 89 cases managed under the model of graded diagnosis, treatment and family doctor team were in the observation group, while 75 managed under the traditional model were in the control group.The compliance, blood glucose, blood lipid, blood pressure and awareness rate of health knowledge were compared between the two groups. Results The compliance scores were significantly higher in the observation group than that in the control group both at 3 month and one year time points after the intervention(6.35 ±2.05 vs 5.39 ±1.17;7.19 ±2.54 vs 5.87 ±1.21;, P<0.05).One year after the intervention, the serum levels of fasting blood glucose(FPG), glycosylated hemoglobin(HbA1 c), 2 hour post blood glucose(2 hPG), total cholesterol(TC), low density lipoprotein cholesterol(LDL-C) and glycerol(TG), as well as systolic blood pressure(SBP) and diastolic blood pressure(DBP) in the observation group were 8.71±1.94 mmol/L,7.52±1.58%,8.84±2.32 mmol/L,4.71±1.74 mmol/L,2.59±0.91 mmol/L,1.69±0.80 mmol/L,(136±22 mmHg,75±6 mmHg),which were lower than those in the control group(9.48±2.07 mmol/L,8.35±1.97%,9.69±2.88 mmol/L,5.29±1.86 mmol/L,3.05±0.97 mmol/L,2.06±0.91 mmol/L),(3.05±0.97 mmHg,,81±9 mmHg;P<0.05).After the intervention,the health knowledge awareness rate,the compliance rate,the rate of regular self-monitoring of blood glucose,the glucose-target-rate and the blood lipid-target-rate were significantly higher in the observation group than those in the control group(6966%vs 53.33%,77.53%vs 62.67%,73.03% vs 53.33%,69.66% vs 53.33%,39.33 vs 22.66%,P<0.05),while the difference in blood pressure-target-rate was not significant between the two group(30.34%vs 29.33%,P>0.05). Conclusions The management of community diabetes under the model of graded diagnosis,treatment and team of family doctors is more effective.it can improve the healthy behavior of patients to control their blood sugar,blood lipid and blood pressure.