区域居民健康的慢病管理模式探索:以医联体糖尿病管理为例  

The Exploration of the Management Model of Chronic Diseases of Regional Residents’Health:Taking Diabetes Management of Medical Alliance as an Example

作　　者：周莹[1] 马志敏 陈志航 王诚[1] 吴雪良 熊文 孙晓鸣 茅国芳[1] 薛鹏[1] 曹海红 连斌 ZHOU Ying;MA Zhimin;CHEN Zhihang(Affliated Suzhou Science Technology Town Hospital,Nanjing Medical University,Suzhou,Jiangsu,215153,China;不详)

机构地区：[1]南京医科大学附属苏州科技城医院,江苏苏州215153 [2]苏州高新区社会事业局,江苏苏州215163 [3]苏州高新区通安卫生服务中心,江苏苏州215153

出　　处：《中国卫生质量管理》2020年第4期150-152,共3页Chinese Health Quality Management

基　　金：苏州高新区医疗卫生科技计划项目(2016Z001,2017Z002,2018Z012);南京医科大学科技发展基金一般项目“探究2型糖尿病患者的血清鞘磷脂水平与脑认知功能之间的关系”(NMUB2018210)。

摘　　要：目的 探索基于医联体平台的糖尿病一体化管理模式,旨在提高社区糖尿病患者管理效率.方法 基于紧密型医联体构建统一HIS系统,对社区糖尿病患者实施一体化远程管理.结果 实施6个月后,糖尿病患者HbA1C[(7.35±1.24)%]较干预前[(7.59±1.58)%]显著下降(P<0.05),87名(44.6%)患者HbA1C达标(<7.0%),较干预前84名(41.4%)有所提高.结论 基于医联体平台的糖尿病一体化管理模式能够提高糖尿病患者血糖管理效率,为规范化管理基层糖尿病患者提供了保证.Objective To explore the integrated diabetes management model based on medical association,to improve the management efficiency of diabetes patients in the community.Methods A unified HIS system was constructed based on the compact medical union,and integrated remote management was implemented for diabetic patients in the community.Results after 6 months of management intervention,the mean value of HbA1 Cof diabetic patients was significantly lower than that before intervention(7.35±1.24%vs.7.59±1.58%,P<0.05),and 87(44.6%)patients reached the standard of HbA1 C(<7.0%),which was higher than that before the intervention(41.4%)in 84 patients.Conclusion The integrated diabetes management model can improve the efficiency of blood glucose management in patients with diabetes and provide a guarantee for the standardized management of patients with diabetes.

关 键 词：紧密型医联体 糖尿病 血糖管理 

分 类 号：R197.1[医药卫生—卫生事业管理] R72[医药卫生—公共卫生与预防医学]