摘要
目的 探讨“五维一体”慢病管理模式对糖尿病(diabetes mellitus,DM)和(或)高血压(hypertension,HT)患者的管理效果。方法 采用整群抽样方法选取2020年12月至2021年3月怀柔区6个村DM和(或)HT患者181例,根据慢性病类型分为DM+HT组(89例)、HT组(92例)。随访6个月,比较“五维一体”慢病管理模式前后两组患者的血糖(blood glucose,BG)、BP等指标的变化。结果 181例患者均完成随访,其中男59例,女122例;年龄42.1~91.9岁,平均(66.9±8.3)岁。DM+HT组平均年龄(66.8±8.4)岁,HT组平均年龄(67.0±8.3)岁。经“五维一体”慢病管理6个月后,DM+HT组的BMI、体质量、糖化血红蛋白(glycated haemoglobin,HbA1c)低于基线水平[(26.00±3.95)kg/m^(2)比(26.33±3.95)kg/m^(2)、(67.92±10.07)kg比(68.79±10.19)kg、(7.26±1.02)%比(7.77±1.45)%],HT组SBP、DBP低于基线水平[(146.74±18.98)mmHg比(153.52±21.19)mmHg、(84.75±11.19)mmHg比(87.68±11.60)mmHg,1 mmHg=0.133 kPa],BP达标比例高于基线水平(42.39%比19.57%),差异均有统计学意义(P<0.05)。随访6个月后,DM+HT组有效管理患者的HbA1c、DBP低于非有效管理患者[(7.04±0.84)%比(8.11±1.34)%、(83.59±9.79)mmHg比(84.42±8.94)mmHg],HbA1c达标率高于非有效管理患者(50.79%比23.08%),差异均有统计学意义(P<0.05)。结论 北京市怀柔区“五维一体”慢病管理模式可有效改善患者血糖和血压水平,为慢病管理模式的推广提供了经验。
Objective To explore the management effect of the "five-dimensional integration" chronic disease management mode on patients with diabetes mellitus(DM) and/or hypertension(HT).Methods A total of 181 patients with DM and/or HT from six villages in Huairou District from December 2020 to March 2021 were selected,and were divided into DM + HT group(89 cases) and HT group(92 cases) according to the type of chronic diseases.Blood glucose(BG) and BP level before and after 6 month of management with "five-dimensional integration" were compared in the two groups.Results A total of 181 patients were followed up for 6 months,including 59 males and 122 females,aged from 42 to 92 years,with an average age of(66.9 ± 8.3) years.The average age of DM + HT group was(66.8 ± 8.4) years,and that of HT group was(67.0 ± 8.3) years.After six months of "five-dimensional integration" chronic disease management,BMI,body weight and glycated haemoglobin(HbA1c) were lower than baseline in the DM + HT group [(26.00 ± 3.95) kg/m^(2)vs.(26.33 ± 3.95) kg/m^(2),(67.92 ± 10.07)kg vs.(68.79 ± 10.19) kg,(7.26 ± 1.02)% vs.(7.77 ± 1.45)%],SBP and DBP were lower than baseline in HT group[(146.74 ± 18.98) mmHg vs.(153.52 ± 21.19)mmHg,(84.75 ± 11.19) mmHg vs.(87.68 ± 11.60) mmHg,1 mmHg =0.133 kPa],the control rates of BP was higher than baseline(42.39% vs.19.57%),and the differences were statistically significant(P<0.05).The HbA1c and DBP of DM + HT group with effective management were lower than those patients without effective management [(7.04 ± 0.84) % vs.(8.11 ± 1.34) %,(83.59 ± 9.79) mmHg vs.(84.42 ± 8.94) mmHg],the control rates of HbA1c was higher than those patients without effective management(50.79% vs.23.08%) after 6 month of follow up,and the differences were statistically significant(all P<0.05).Conclusions The "five-dimensional integration" chronic disease management model in Huairou District can effectively improve BG and BP levels of the patients,which provides an empirical basis for the promotion of chronic disease mana
作者
田勇
张楠
杨正强
赫兴华
任国钰
张雪柔
刘一潼
王惠
果艳霞
杨凯文
张鹏
赵泽敏
阮丹杰
Tian Yong;Zhang Nan;Yang Zhengqiang;He Xinghua;Ren Guoyu;Zhang Xuerou;Liu Yitong;Wang Hui;Guo Yanxia;Yang Kaiwen;Zhang Peng;Zhao Zemin;Ruan Danjie(Department of Endocrinology,Beijing Huairou Hosipital,Beijing 101400,China)
出处
《北京医学》
CAS
2023年第4期294-298,303,共6页
Beijing Medical Journal
关键词
五维一体
慢病管理
糖尿病
高血压
管理效果
five-dimensional integration
chronic disease management
diabetes mellitus(DM)
hypertension(HT)
management effect