紧密型医联体双向转诊模式下社区2型糖尿病患者的管理效果研究  

Study on the management effectiveness of patients with type 2 diabetes in the community under the bi-directional referral system of close-knit medical consortium

作　　者：王凤微 侯丹阳 王杰萍[2] 杨兴华[1] WANG Fengwei;HOU Danyang;WANG Jieping;YANG Xinghua(School of Public Health,Capital Medical University,Beijing 100069,China;Department of General Practice,Fuxing Hospital,Capital Medical University,Beijing 100038,China)

机构地区：[1]首都医科大学公共卫生学院,北京100069 [2]首都医科大学附属复兴医院全科医学科,北京100038

出　　处：《卫生软科学》2024年第9期12-17,共6页Soft Science of Health

基　　金：北京市西城区财政科技专项项目(XCSTS-SD2018-10)。

摘　　要：[目的]评价紧密型医联体双向转诊模式下社区2型糖尿病(T2DM)患者的管理效果,为该模式的优化和推广提供参考。[方法]选取2019年1-12月通过“复兴医院-月坛社区紧密型医联体”信息化双向转诊平台转诊的2型糖尿病患者为转诊组(n=79);选取同期未进行转诊的月坛社区2型糖尿病患者为未转诊组(n=85)。采用结构化问卷收集2组患者的社会人口学信息、健康相关态度和行为、健康状况指标及实验室检查指标,同时记录转诊组患者的转诊原因和转诊去向。对转诊组患者随访12个月,记录其转诊后6个月和12个月的血糖和血脂指标。[结果]转诊组患者的年龄、非在婚比例、“一老一小”参保比例、患慢性病种数高于非转诊组患者(P<0.05);空腹血糖(FPG)、糖化血红蛋白(HbA 1c)水平高于非转诊组患者(P<0.05)。79例转诊组糖尿病患者的转诊原因排在首位的是“血糖波动较大,社区处理困难,无法平稳控制”[31例(39.2%)],转诊去向排在首位的是“进一步到内分泌专科门诊就诊”[37例(46.8%)]。转诊后6个月,转诊组患者的FPG、HbA 1c水平低于转诊前(P<0.05);转诊后12个月,转诊组患者的FPG、HbA 1c、甘油三酯(TG)水平低于转诊前(P<0.05),HbA 1c水平低于转诊后6个月(P<0.05)。[结论]高龄、非在婚、参保“一老一小”、患多种慢性病的社区T2DM患者具有更高的向上转诊需求,紧密型医联体双向转诊模式可以提高社区T2DM患者的管理效果,优化后的“复兴医院-月坛社区紧密型医联体”运行模式具有一定的可推广性。Objective To evaluate the management effectiveness of patients with type 2 diabetes mellitus(T2DM)in the community under the bi-directional referral system of close-knit medical consortium,and to provide the reference for the optimization and promotion of the system.Methods Patients with type 2 diabetes referred through the bi-directional referral information platform of close-knit medical consortium between health service centers in Yuetan community and Fuxing Hospital from January to December 2019 were selected as the referral group(n=79).Patients with type 2 diabetes who had not been referred in the same period in Yuetan community were selected as the non-referral group(n=85).Socio-demographic information,health-related attitudes and behaviors,health status indicators and laboratory examination indicators of patients in two groups were collected by structured questionnaires.The reasons for referral and the destination of referral were also recorded.Patients in the referral group were followed up for 12 months,and their blood glucose indexes and blood lipid indexes were recorded at 6 and 12 months after referral.Results Patients age,unmarried proportion,the proportion of insured the old and the young,and the number of chronic diseases in the referral group were higher than those in the non-referral group(P<0.05).Fasting blood glucose(FPG)and glycated hemoglobin(HbA 1c)levels were higher than those in the non-referral group(P<0.05).Among the 79 patients with diabetes in the referral group,the primary reasons for referral were“significant fluctuations in blood glucose,difficulty in community treatment,and inability to stabilize control”[31 cases(39.2%)].The primary destination for referral was“further consultation at the endocrinology specialist outpatient clinics”[37 cases(46.8%)].Six months after referral,the FPG and HbA 1c levels of patients in the referral group were lower than those before referral(P<0.05).12 months after referral,the levels of FPG,HbA 1c and triglyceride(TG)in the referral group wer

关 键 词：紧密型医联体 双向转诊 区域协同医疗 2型糖尿病 卫生信息化 

分 类 号：R197[医药卫生—卫生事业管理]