上海市某农村社区老年糖尿病患者精细化管理效果分析

The Effect Analysis of Delicacy Management for the Elderly Patients with Diabetes in a Rural Community in Shanghai

目的了解农村地区糖尿病患者血糖控制水平,探索综合干预模式。方法在上海市青浦区某农村社区募集78名老年糖尿病患者,对其开展血糖评估后,通过建立糖尿病自我管理小组,依托医院、疾控、社区和家庭开展患者健康自我管理。通过健康教育、适当运动、健康饮食、规律服药、及时就诊等途径开展血糖控制。结果干预前患者空腹血糖平均为7.90 mg/L,干预后空腹血糖下降至6.46mg/L,尿酸由104.72 mg/L降至82.38 mg/L,总胆固醇水平由5.20 mg/L降至4.86 mg/L,以上各组指标差异有统计学意义,其余指标差异则无统计学差异。结论通过建立社区居民健康管理小组,依托医院专家、社区服务、疾控和患者家庭的共同作用,可以将患者血糖控制在比较理想的水平,降低并发症的发病风险。

Objective To understand the blood glucose control level of the patients with diabetics in country, search for the intervention model. Methods A total of 78 aged patients with diabetics in rural community of Qingpu District had been under the health self-management which based on hospital-CDCcommunity-family. Results the average blood glucose levels of these patients were 7.90mg/L and 6.45mg/L respectively before and after the intervention, and the average uric acid decreased to 82.38mg/L from 104.72mg/L, the average total cholesterol decreased to 4.86mg/L from 5.20mg/L. And the differences of these indexes had statistical significances. Conclusion By health self-management group, based on the hospital-communityservice-CDC and family intervention, blood glucose can been controlled in a good level, to reduce the risk of disease.