摘要
目的探讨社区糖尿病的有效管理模式与适宜干预方法。方法将社区183例2型糖尿病患者随机分成两组,即强化管理(Ⅰ组)和标准管理(Ⅱ组),其中Ⅰ组99人、Ⅱ组84人。Ⅰ组进行强化管理:由以全科医师-内分泌专家共同参与的健康管理团队,对糖尿病患者进行主动、定期(每两月一次)随访,内分泌专家直接参与指导糖尿病患者的管理;严格糖尿病教育,定期举行糖尿病健康促进专题讲座、发放宣传资料,除讲课外要有考评,坚持患者行为干预与药物治疗并重;建立社区与三级医院双向转诊关系,对糖化血红蛋白(HbA1c)>9%或发生并发症的患者转诊至其内分泌科进一步诊治。Ⅱ组进行标准管理:由全科医师对糖尿病患者进行管理,给予健康教育(至少每年一次),指导合理膳食和运动,每6个月复诊一次。管理期为3年。评价管理前后患者的FPG、2hPG、HbA1c、TG和LDL-C等生化指标的差异等。结果管理前,Ⅰ组和Ⅱ组两组相关生化指标之间的差异无统计学意义(P>0.05)。Ⅰ组管理前和管理后的FPG、2hPG、HbA1c、TG和LDL-C之间差异具有统计学意义(P<0.05);Ⅱ组管理前和管理后生化指标间差异无统计学意义(P>0.05)。结论联合社区卫生资源和三级医院技术优势,建立全科医生-专家团队,有利于提高全科医师的糖尿病管理能力,明显改善糖尿病患者血糖和糖化血红蛋白等生化指标。
Objective To investigate the effective mod of management and the appropriate intervention to the diabetes in community.Methods We randomly divided 183 patients with diabetes into two groups.We treated groupⅠ which had 99 patients with intensive management and groupⅡ(84patients)with normal management.The intensive management on groupⅠ:The health management team consisted with general practitioners and endocrinologists followed up the patients actively and termly(once every two months).The endocrinologists directly took part in the management to the patients.Strictly taught diabetes knowledge,hold diabetes health promotion seminar termly,and distribute publicity materials.We also evaluated the teaching and insist that behavior intervention and drug treatment have the same importance.We build the two-way transfer relationships between community and tertiary-level hospitals and transferred the patients whose HbA1 ccontent was above 9%or with complications to the department of endocrinology.The groupⅡtreatment:give patients follow-up once every 6months.After 3years management,evaluate the difference before and after treatment on the level of FPG,2hPG,HbA1 c,TG,LDL-C and so on.Results Before the management,the two groups had no significant differences on these indicators.But there had significant differences(P<0.05)in groupⅠ before and after treatment but groupⅡdidn't(P>0.05).Conclusion The joint of the community health resources and the technical advantages of the tertiary-level hospitals and the building of the generalexperts teams can improve the ability of the general doctors on the management of diabetes.And it can improve the health of the diabetes patients on the level of blood sugar,glycated hemoglobin and other biochemical indicators.
出处
《中国地方病防治》
2014年第S2期330-331,共2页
Chinese Journal of Control of Endemic Diseases
关键词
社区卫生服务
糖尿病
管理模式
Community Health Services
Diabetes
Management Method
