分阶段达标管理模式对社区老年2型糖尿病患者干预效果分析  

Intervention Effect of Staged Target Management Model on Elderly Patients with Type 2 Diabetes in Community

作　　者：俞匀[1] 娄青林[1] 唐伟[1] Yu Yun;Lou Qinglin;Tang Wei(Department of Endocrinology, Jiangsu Province Official Hospital, Nanjing, Jiangsu Province, 210024, P. R. China)

机构地区：[1]江苏省省级机关医院内分泌科,江苏南京210024

出　　处：《老年医学与保健》2017年第6期516-519,共4页Geriatrics & Health Care

基　　金：国家自然科学基金面上项目(71373132);江苏建康职业学院项目(JKA201601)

摘　　要：目的探讨"5+1"分阶段达标管理模式("5+1"模式)对社区老年2型糖尿病患者血糖、血压和血脂的干预效果。方法从南京市鼓楼区10个社区卫生服务中心选取自2013年1月起纳入管理的老年2型糖尿病患者3 650例,从中筛选含自纳入起3~6个月、6~12个月及末次随访资料患者1 658例。所有患者均采用"5+1"模式进行随访干预,分别收集患者管理前、基线、第1次随访(3~6个月)、第2次随访(6~12个月)及末次随访资料,包括患者一般临床资料、各项代谢指标及相关糖尿病并发症检查等。结果患者末次随访的糖化血红蛋白(HbA1c)、空腹血糖(FPG)、餐后2 h血糖(2hPG)、收缩压(SBP)、舒张压(DBP)、总胆固醇(TC)、三酰甘油(TG)、低密度脂蛋白胆固醇(LDLC)比基线降低,高密度脂蛋白胆固醇(HDL-C)比基线升高,差异均有统计学意义(均P<0.05);末次随访的血糖、血压、血脂单项达标率及3项综合达标率与基线比较均显著升高,差异均有统计学意义(HbA1c达标率从53.00%升高至64.23%,血压达标率从67.80%升高至85.17%,LDL-C达标率从44.99%升高至51.77%,3项达标率从18.33%升高至29.62%,均P<0.01)。结论 "5+1"模式能提高社区老年2型糖尿病患者的血糖、血脂和血压达标率,值得被广泛使用。Objective To explore the intervention effect of"5+1"staged target management model on blood glucose,blood pressure and blood lipid of the elderly patients with type2diabetes in community.Methods3650elderly with type2diabetes under the management of10community health service centers of Gulou District,Nanjing since Jan.,2013were enrolled,out of whom,1658patients with the follow-up data within3to6months after listed in the management,the data within6to12months and the data of latest follow-up were selected;follow-up intervention of"5+1"staged target management model had been performed on all the patients;the data of the patients before being listed in the management,at base-line,the first follow-up(within3to6months),the second follow-up(within6to12months)and the latest follow-up were collected,including the general clinical information,metabolismindex and the examinations of complications related to diabetes.Results The levels of HbA1c,FPG,2hPG,systolic pressure,diastolic pressure,TC,TG,LDL-C of the patients in the latest follow-up were all higher than those at base-line with statistical difference(P<0.05);single compliance rate of blood glucose,blood pressure and blood lipid was much higher than that at base-line as well as the general compliance rate of the3items,the difference was of statistical significance(P<0.01).Conclusions Intervention with"5+1"staged target management model can lift the compliance rate of blood glucose,blood lipid and blood pressure of the elderly patients with type2diabetes in community,which is worthy of wider performance.

关 键 词：分阶段达标管理模式 糖尿病 2型 疾病管理 

分 类 号：R473.2[医药卫生—护理学]