糖尿病患者社区规范化管理干预效果评价

目的　探讨社区规范化管理对提升2型糖尿病患者血糖达标率的管理效果。方法　选取2008年北京市朝阳区将台社区卫生服务中心的151例2型糖尿病患者，进行社区规范化管理，每年进行4次健康体检，收集收缩压、舒张压、空腹血糖（FPG）、餐后2 h血糖（2 hPG）及糖化血红蛋白（HbA1c）等资料。到2016年，规范化管理满8年且资料齐全的患者共计111例，其中单纯糖尿病患者44例（39.6%，单纯糖尿病组），糖尿病合并高血压患者67例（60.4%，糖尿病合并高血压组）。对调查对象2008年与2016年两次数据进行比较分析。结果　单纯糖尿病组女性舒张压与管理前组相比有所下降，糖尿病合并高血压组收缩压和舒张压与管理前相比均有所下降，差异有统计学意义（95%CI不包括0）。单纯糖尿病组女性FPG与管理前相比有所下降，单纯糖尿病组、糖尿病合并高血压组2 hPG、HbA1c与管理前相比有所下降，差异有统计学意义（95%CI不包括0）。糖尿病的整体达标率由2008年的34.2%（38/111）上升至2016年的60.4%（67/111），差异有统计学意义（χ2=15.198，P<0.001）。其中，单纯糖尿病组的血糖达标率由31.8%（14/44）上升至56.8%（25/44），糖尿病合并高血压组的血糖达标率由35.8%（24/67）上升至62.7%（42/67），差异有统计学意义（χ2=5.272，P=0.018；χ2=10.942，P<0.001）。单纯糖尿病组除男性、年龄≥60岁、受教育程度为高中及以上、饮食规律、有高血压家族史者管理后血糖达标率与管理前无差异，服药依从性差患者血糖达标率低于管理前外，其他亚组血糖达标率均高于管理前，差异有统计学意义（95%CI不包括0）。糖尿病合并高血压组除吸烟、服药依从性差、有糖尿病家族史者管理后血糖达标率与管理前无差异外，其他亚组血糖达标率均高于管理前，差异有统计学意义（95%CI不包括0）。结论　在社区开展糖尿病规范化管理可以改善糖尿病患者的血压、血糖水平，提高糖尿病的控制效果。

Effect of Community-based Standardized Management on Diabetic Patients

Objective　To evaluate the effects of community-based standardized management on the rate of meeting the glycemic targets in type 2 diabetic patients.Methods　We enrolled 151 type 2 diabetic patients who received community-based standardized glycemic control management from Jiangtai Community Health Center in Bejing's Chaoyang District in 2008.All of them underwent 4 times of physical examination per year.We collected their data such as systolic blood pressure（SBP），diastolic blood pressure （DBP），fasting plasma glucose（FPG），2-hour postprandial blood glucose（2 hPG），glycosylated hemoglobin （HbA1c） and so on between 2008 and 2016.A total of 111 cases with 8-year （from 2008 to 2016） community-based standardized management and complete data were finally included in the study，including 44 （39.6%） with simple type 2 diabetes （simple diabetes group），and 67 （60.4%） with type 2 diabetes combined with hypertension （diabetes combined with hypertension group）.Comparatively analyzed the data measured in 2008 and 2016.Results　Compared with 2008，in 2016，both SBP and DBP decreased in females significantly in diabetes combined with hypertension group，but only DBP decreased obviously in simple diabetes group with statistical significances （95%CI did not include 0）.Moreover，FPG declined in females in simple diabetes group，2 hPG and HbA1c declined substantially in both groups with statistical significances （95%CI did not include 0）.The rate of meeting glycemic targets increased significantly in all participants〔60.4%（67/111） vs 34.2%（38/111），χ2=15.198，P<0.001〕 ，simple diabetes group 〔56.8% （25/44） vs 31.8% （14/44）， χ2=5.272，P=0.018〕 ，and diabetes combined with hypertension group 〔62.7% （42/67） vs 35.8% （24/67） ，χ2=10.942，P<0.001〕 in 2016 compared with 2008.In the simple diabetes group，except male，aged ≥60，a high school education or higher，eating properly，and family history of hypertension that were associated with little changed rate of meeting glycemic targets，poor drug compliance was associated with significantly decreased rate of meeting glycemic，other demographic factors were associated with significantly increased rate of meeting glycemic targets with statistical significant differences （95%CI did not include 0）.In the diabetes combined with hypertension group，except smoking，poor drug compliance，and family history of diabetes were associated with little changed rate of meeting glycemic targets，other demographic factors were associated with significantly increased rate of meeting glycemic targets with statistical significant differences （95%CI did not include 0）.Conclusion　Results from our study showed that community-based standardized glycemic control management could significantly improve the levels of blood pressure and glycemic control status.