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目的探讨社区慢性病管理模式及疗效。方法对某社区2008年1—6月及2009年同期已确诊的60岁以上糖尿病、高血压患者依据《天津市城市社区公共卫生服务项目工作指南》进行规范化管理。结果 2008年糖尿病控制满意率1—6月有逐渐升高趋势(2月份除外),糖尿病控制满意率最低在2月(13.6%),最高在6月(23.6%);2009年糖尿病控制满意率1—6月有逐渐升高趋势(2月份除外),控制满意率最低在2月(14.6%),最高在6月(30.9%)。高血压控制满意率最低在2008年2月(25.6%),最高在2009年6月(42.9%)。2009年糖尿病、高血压控制满意率较2008年同期明显提高(P<0.05),差异有统计学意义。结论社区对糖尿病、高血压实施规范化管理可以降低糖尿病、高血压患者的血糖、血压,但总体控制满意率仍偏低。提示管理模式还不够完善,专业管理能力尚存在一定缺陷。
Objective To explore community chronic disease management and efficacy. Methods The standardized management of a community with diabetes and hypertension over 60 years of age diagnosed in the first six months of 2008 and the same period of 2009 was conducted according to the Guidelines for Urban Community Public Health Services in Tianjin. Results The satisfaction rate of diabetes control in 2008 increased gradually from January to June (except in February), and the satisfaction rate of diabetes control was the lowest in February (13.6%) and the highest in June (23.6%). The satisfaction rate of diabetes control in 2009 From January to June, there was a gradual upward trend (except in February), with the lowest rate of satisfactory control being in February (14.6%) and the highest in June (30.9%). The lowest satisfaction rate of hypertension control was in February 2008 (25.6%) and the highest in June 2009 (42.9%). The satisfaction rate of diabetes and hypertension control in 2009 was significantly higher than that of the same period of 2008 (P <0.05), the difference was statistically significant. Conclusion Community-based management of diabetes mellitus and hypertension can reduce the blood sugar and blood pressure in patients with diabetes mellitus and hypertension, but the overall control satisfaction rate is still low. Prompt management mode is not perfect, professional management capabilities still exist some flaws.