摘要
目的建立社区糖尿病患者的医院-社区管理模式,并探讨其管理效果。方法选取武陵山片区怀化市城北社区45名糖尿病患者,建立医院-社区管理模式,对纳入患者管理3个月,比较管理前后患者糖化血红蛋白(GHb)、甘油三酯、血压等指标的达标率,以及个体化治疗知晓率、3个月复诊率、并发症筛查率、低血糖发生率,比较社区医护人员在专科医师指导前后糖尿病专科知识水平。结果建立了比较适合该社区的医院-社区管理的具体实施模式以及45份糖尿病患者医院-社区互联电子档案。干预后45例糖尿病患者GHb、甘油三酯、血压等达标率以及个体化治疗知晓率、3个月复诊率、并发症筛查率均较前提高(P<0.05),低血糖发生率降低(P<0.05)。16名社区医护人员在专科医师指导后糖尿病专业知识笔试分数由(48.1±10.4)分上升至(85.3±6.1)分(P<0.05)。结论所建立的医院-社区管理模式能更好地让糖尿病患者进行长期个体化、规范化治疗,有利于患者病情的控制,更符合我国国情。
Objective To establish a hospital-community management model for patients with diabetes from the community, and to evaluate its management efficacy. Methods Forty-five patients with diabetes from Chengbei community of Huaihua in Wulingshan District were enrolled. A hospital-community management model was established and conducted in the included patients for three months. The qualified rates of glycosylated hemoglobin ,triglycerides and blood pressure ,awareness rate of individualized treatment ,return visit rate after three months, screening rate of complication ,and incidence rate of hypoglycemia were compared before and after management. The professional knowledge about diabetes in the community physicians were compared before and after the guidance by specialty physicians. Results The appropriate specific application model of hospital-community management for this community was established, and 45 copies of hospital-community interconnected electronic records were set up for the patients. Among the 45 patients with diabetes, after intervention, the qualified rates of glycosylated hemoglobin, triglycerides and blood pressure, the awareness rate of individualized treatment, return visit rate after three months, and screening rate of complication increased（ P 〈 0.05 ）, and the incidence rate of hypoglycemia decreased（ P 〈 0.05 ）. Among 16 community physicians, after the guidance by specialty physicians, the examination scores of professional knowledge about diabetes increased from （48.1 ± 10.4） points to （85.3 ± 6.1 ） points （P 〈 0.05 ）. Conclusion The established hospital-community management model can provide better long-term individualized and standardized treatment for the patients with diabetes, is conducive to the disease control, and more appropriate for national conditions.
出处
《广西医学》
CAS
2016年第12期1654-1657,共4页
Guangxi Medical Journal
基金
湖南医药学院科研项目(2012KY06)
关键词
糖尿病
医院-社区
管理模式
湖南
武陵山
Diabetes, Hospital-community, Management model, Hunan, Wuling mountain region
