安阳市糖尿病社区—医院一体化管理效果评价

Evaluation for effects of community-hospital integrated management system on diabetes patients in Anyang

目的对安阳市糖尿病社区—医院一体化管理3年的效果进行评价。方法安阳市卫生局分别在疾控机构、社区医院、综合医院成立管理团队,形成由疾控机构为主导的糖尿病社区—医院一体化管理模式,实行社区与医院间双向转诊,对糖尿病患者实行无缝化管理。收集、分析管理3年的数据,对管理效果进行评价。应用Epi Data 3.0软件建立数据库,进行数据录入;应用SPSS 13.0统计软件进行数据统计分析。计量资料以(xˉ±s)表示,组间比较采用t检验;计数资料采用百分比表示,组间比较采用χ2检验。P<0.05为差异有统计学意义。结果管理满3年时,与建档时相比,患者空腹血糖、糖化血红蛋白、糖化血红蛋白、收缩压、舒张压、总胆固醇、甘油三酯、低密度脂蛋白胆固醇等临床指标均值显著降低(P<0.05),各项指标控制率显著提高(P<0.05);患者生活方式较管理前更加健康,70.62%的患者锻炼次数和锻炼时间有所增加。结论安阳市糖尿病社区—医院一体化管理,通过整合多方医疗卫生资源,取得了比较满意的管理效果。

Objective To evaluate effects of 3 years community-hospital integrated management system on diabetes patients in Anyang. Methods Management teams were set up by Anyang Department of Health in Center of Disease Control and Prevention(CDC), community hospitals, and general hospitals.A community- hospital integrated management system led by CDC was formed to treat diabetes patients. Patients were treated with bidirectional referral care between communities and hospitals, which limited the referral period. 3 years of data were collected and analyzed to evaluate the management system. Epi Data 3.0 was used to set up the dataset. SPSS 13.0 was used to analyze the dataset. Continuous variables were described with mean±SD and compared between groups with t-test. Categorical variables were described with percentage and compared between groups with Chi- square test. Results Compared with 3 years ago, biochemical and clinical indicators among diabetes patients, including fasting blood glucose, glycosylated hemoglobin, systolic and diastolic blood pressure, total cholesterol,triglycerides, and low- density lipoprotein, have improved significantly(P<0.05). The control rates of these indicators were also improved(P<0.05). Compared to 3 years before, the life styles of patients were healthier, and 70.62% patients had more exercises. Conclusions The community-hospital integrated management system in Anyang was effective with utilizing multi-health resources.