家庭医生对2型糖尿病签约患者实施一体化全-专联合管理的效果观察  

Effect Observation of Integrated Full-Professional Joint Management by Family Doctors in Contracted Patients with Type 2 Diabetes Mellitus

作　　者：袁梅娟 张继学 郑滔 许洁 吴茹英 Yuan Meijuan;Zhang Jixue;Zheng Tao;Xu Jie;Wu Ruyin(Shanghai Fengxian District Xidu Street Community Health Service Center,Shanghai 201401,China)

机构地区：[1]上海市奉贤区西渡街道社区卫生服务中心,上海201401

出　　处：《中国社区医师》2023年第22期151-153,共3页Chinese Community Doctors

基　　金：上海市奉贤区科委(社会类)科技发展基金项目(奉科20181921)。

摘　　要：目的:探讨家庭医生对2型糖尿病(T2DM)签约患者实施一体化全-专联合管理(简称一体化管理)的效果。方法:选取2018年1—12月于上海市奉贤区西渡街道社区卫生服务中心进行家庭医生签约的T2DM患者298例作为研究对象,采用随机数字表法分为干预组(n=156)及对照组(n=142)。干预组实施一体化管理,对照组实施常规社区管理。比较两组干预效果。结果:干预后,干预组收缩压低于对照组,糖尿病患者自我管理行为量表评分高于对照组,差异有统计学意义(P<0.05)。干预后,干预组空腹血糖、餐后2 h血糖、血红蛋白水平均低于对照组,差异有统计学意义(P<0.05)。干预后,干预组LDL-C及尿酸水平低于对照组,差异有统计学意义(P<0.05)。干预组空腹血糖达标次数多于对照组,差异有统计学意义(P=0.002)。结论:家庭医生对T2DM患者实施一体化管理,可以有效改善患者血糖及生化指标,提高血糖达标率及自我管理能力。Objective:To explore the effect of family doctors' integrated full-professional joint management(hereinafter referred to integrated management) in contracted patients with type 2 diabetes mellitus(T2DM).Methods:A total of 298 patients with T2DM contracting family doctor service in Shanghai Fengxian District Xidu Street Community Health Service Center from January2018 to December 2018 were selected as the study subjects.They were divided into intervention group(n=156) and control group(n=142) according to random number table method.Integrated management was performed in the intervention group,while routine community management was performed in the control group.The intervention effects were compared between the two groups.Results:After the intervention,the systolic blood pressure in the intervention group was lower than that in the control group,and the scores of the self-management behavior scale of diabetic patients in the intervention group were higher than those in the control group,and the difference was statistically significant(P<0.05).After the intervention,the fasting blood glucose,2 h postprandial blood glucose and hemoglobin levels in the intervention group were lower than those in the control group,and the differences were statistically significant(P<0.05).After the intervention,LDL-C and uric acid levels in the intervention group were lower than those in the control group,and the differences were statistically significant(P<0.05).The number of times of reaching the standard of fasting blood glucose in the intervention group was higher than that in the control group,and the difference was statistically significant(P=0.002).Conclusion:The integrated management of T2DM patients by family doctors can effectively improve their blood glucose and biochemical indexes,increase blood glucose compliance rate and self-management ability.

关 键 词：家庭医生 2型糖尿病 一体化管理 血糖 

分 类 号：R587.1[医药卫生—内分泌]