社区2型糖尿病长期路径化干预管理模式的研究  

A Study of Community Long-term Pathway Intervention Management Model of Type 2 Diabetes

作　　者：杨斌[1] 王志忠[1] 王晶[1] 胡叶暖[1] 王亚平[1] 

机构地区：[1]北京北京军区总医院第三门诊部,100012

出　　处：《华南国防医学杂志》2014年第11期1104-1106,共3页Military Medical Journal of South China

摘　　要：目的分析长期路径化干预管理模式在社区糖尿病管理中干预的流程、内容和效果,为完善推广社区糖尿病长期路径化管理模式提供依据。方法选取本社区210名2型糖尿病患者,遵循路径化流程和表单式项目管理内容,依据路径项目完成率分为80%以上组（第一组）、60%~80%组（第二组）、60%以下组（第三组）,观察三组患者的干预后指标整体达标率情况和空腹血糖、餐后2 h血糖、糖化血红蛋白变化情况。结果 80%以上组、60%~80%组、60%以下三个组,指标整体达标率分别为90.2±2.13;84.5±3.15;75.4±3.26。第二组与第一组在餐后2 h血糖、糖化血红蛋白有显著性差异,第三组与第一组在空腹血糖、餐后2 h血糖、糖化血红蛋白上均有显著性差异。结论社区糖尿病路径化管理明确了糖尿病医患双方的管理流程和相关内容,尤其是强化了患者的依从性,促进了社区糖尿病管理控制整体水平的提高。Objective To analyze the long-term pathway intervention management model in community management of diabetes in the process content and effect to improve long-term pathway management model of diabets.MethodsTo select 210 type 2 diabetes patients within the community,in accordance with the pathway process and the contents of table and list-type item management,then to divide them into three groups on the basis of their accomplishment percentage of pathway items,group 1（over 80%）、group 2（60-80%）and group 3（under 60%）,and then to make an observation of the general accomplishment percentages in intervention targets of the patients of three groups and the changes of fasting plasma glucose（FPG）,2 hours plasma glucose（2hPG）and glycosylated hemoglobin A1c（HbA1c）of the three groups after intervention.Results The general target accomplishment percentages of the three groups in the order of over80%,60-80% and under 60% were 90.2±2.13,84.5±3.15 and 75.4±3.26 respectively.There were significent differences in the control of 2hPG and HbA1 c between the group 1 and group 2 and there were remarkable differences in the control of FPG,2hPG and HbA1 c between the group3 and group1.Conclusion The community pathway management of diabetes has made clear the diabetes management process and its relevant contents between doctors and patients,and it has strengthened the compliance of patients in particular,resulting in the general improvement of community diabetes management and control.

关 键 词：糖尿病 路径化 表单式 社区 

分 类 号：R587.1[医药卫生—内分泌]