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目的探讨社区糖尿病的有效管理模式与适宜干预方法。方法将社区183例2型糖尿病患者随机分成两组,即强化管理(Ⅰ组)和标准管理(Ⅱ组),其中Ⅰ组99人、Ⅱ组84人。Ⅰ组进行强化管理:由以全科医师-内分泌专家共同参与的健康管理团队,对糖尿病患者进行主动、定期(每两月一次)随访,内分泌专家直接参与指导糖尿病患者的管理;严格糖尿病教育,定期举行糖尿病健康促进专题讲座、发放宣传资料,除讲课外要有考评,坚持患者行为干预与药物治疗并重;建立社区与三级医院双向转诊关系,对糖化血红蛋白(HbA1c)>9%或发生并发症的患者转诊至其内分泌科进一步诊治。Ⅱ组进行标准管理:由全科医师对糖尿病患者进行管理,给予健康教育(至少每年一次),指导合理膳食和运动,每6个月复诊一次。管理期为3年。评价管理前后患者的FPG、2hPG、HbA1c、TG和LDL-C等生化指标的差异等。结果管理前,Ⅰ组和Ⅱ组两组相关生化指标之间的差异无统计学意义(P>0.05)。Ⅰ组管理前和管理后的FPG、2hPG、HbA1c、TG和LDL-C之间差异具有统计学意义(P<0.05);Ⅱ组管理前和管理后生化指标间差异无统计学意义(P>0.05)。结论联合社区卫生资源和三级医院技术优势,建立全科医生-专家团队,有利于提高全科医师的糖尿病管理能力,明显改善糖尿病患者血糖和糖化血红蛋白等生化指标。
Objective To explore the effective management of community diabetes mellitus and appropriate intervention methods. Methods A total of 183 patients with type 2 diabetes in the community were randomly divided into two groups: intensive management (group Ⅰ) and standard management (group Ⅱ), with 99 in group Ⅰ and 84 in group Ⅱ. Group Ⅰ intensive management: by a general practitioner - endocrine experts to participate in the health management team, diabetes patients active, regular (once every two months) follow-up, endocrine experts directly involved in guiding the management of diabetic patients; strict diabetes education, Regularly held diabetes health promotion seminars, dissemination of publicity materials, in addition to lectures should have evaluation, adhere to the patient behavior intervention and drug treatment both; community and tertiary hospitals to establish a two-way referral relationship, the glycosylated hemoglobin (HbA1c)> 9% occurred Patients with complications were referred to their endocrine department for further diagnosis and treatment. Group II standard management: by the general practitioner of diabetes management, health education (at least once a year), to guide a reasonable diet and exercise, referral every 6 months. The management period is 3 years. Evaluation of patients before and after the management of FPG, 2hPG, HbA1c, TG and LDL-C and other biochemical indicators of differences. Before the results of management, there was no significant difference in the related biochemical indexes between the two groups (P> 0.05). The differences of FPG, 2hPG, HbA1c, TG and LDL-C between pre-management and post-management in group Ⅰ were statistically significant (P0.05). There was no significant difference in biochemical indexes between pre-management and post-management in group Ⅱ (P> 0.05). Conclusion The combination of community health resources and the technical advantages of tertiary hospitals and the establishment of a general practitioner team of experts help to improve the diabetes management ability of general practitioners and significantly improve the biochemical indexes such as blood glucose and glycosylated hemoglobin in diabetic patients.