我国基层卫生改革措施对糖尿病管理效果的影响研究

背景　基层卫生改革创新性措施对慢性病患者管理效果的影响是政策制定、执行和研究者广泛关注的问题，特别是近3年来开展的基层信息化建设、家庭医生签约服务等。目的　探讨家庭医生签约服务、信息化手段等基层卫生改革措施对糖尿病管理效果的影响，为改善基层糖尿病患者管理提供政策建议。方法　按照立意抽样和随机抽样相结合的方法，于2018年8-10月在我国东中西部3个省4个地市的7家社区卫生服务中心抽取在管糖尿病患者658例。调查其社会人口学、健康行为及基层卫生改革措施接受情况，其中基层卫生改革措施指标包括：是否纳入门诊慢性病报销系统、是否签约家庭医生，以及分时段预约就诊、“互联网+”随访、心脑血管疾病风险评价、远程医疗、电子药盒提醒服务接受情况。采用多元Logistic回归分析糖尿病患者血糖控制的影响因素。结果　糖尿病患者的血糖控制率为43.9%（289/658）。多元Logistic回归分析结果显示，年龄、文化程度、地市、服药依从性、是否签约家庭医生、是否接受过心脑血管疾病风险评价是糖尿病患者血糖能否得到控制的影响因素（P<0.05）。其中，文化程度为大学及以上患者血糖控制率是未上过学患者的2.531倍〔95%CI（1.147，5.582）〕，昆山市患者血糖控制率是常州市患者的1.822倍〔95%CI（1.049，3.167）〕，按说明服药偶尔漏服、严格按医嘱服药患者血糖控制率分别是从不服药患者的3.363倍〔95%CI（1.314，8.610）〕和3.876倍〔95%CI（1.629，9.220）〕，签约家庭医生患者血糖控制率是未签约患者的2.466倍〔95%CI（1.523，3.991）〕，接受过心脑血管疾病风险评价患者血糖控制率是未接受过患者的2.334倍〔95%CI（1.363，3.999）〕。签约家庭医生患者的服药依从性优于未签约患者，接受心血管疾病风险评价的比例高于未签约患者（P<0.05）。结论　家庭医生签约服务和“互联网+”创新性技术应用等基层卫生改革措施已经在糖尿病患者管理中初显效果，且二者具有相互促进作用；基层医务人员主导的信息化手段更易发挥作用，建议进一步推进。

The Effect of Reform Measures in Primary Health Care on the Effectiveness of Diabetes Management in China

Background　The effect of innovative reform measures in primary health care on the management effectiveness of patients with chronic diseases is a matter widely concerned by policymakers，executors and researchers，especially measures as grassroots informatization construction and contracted family doctor services carried out in the past three years.Objective　To explore the effect of grassroots health reform measures such as contracted family doctor services and the application of information technology on the effectiveness of diabetes management，in order to provide recommendations for improving the management of patients with diabetes at grassroots level.Methods　According to the principle of combining purposive sampling and random sampling，658 diabetic patients were selected from 7 community health service centers in 4 cities of 3 provinces in the eastern，central，and western regions of China from August to October in 2018.The data of social demography，health behaviors and acceptance of primary health care reform measures were investigated，among which indicators for primary health care reform measures included whether patients were embedded in the outpatient reimbursement system for chronic diseases，whether they had contracted with family doctors，whether they made appointments for treatment at different period of time，whether they had received Internet plus follow-up，whether they had received cardiovascular and cerebrovascular risk assessment，and whether they had received telemedicine and electronic pill box reminder service.Multivariate Logistic regression was used to analyze the factors influencing blood glucose control in diabetic patients.Results　The glycemic control rate was 43.9%（289/658）.The results of multivariate Logistic regression analysis showed that age，education level，city，medication compliance，whether to contact with a family doctor，and whether to have cardiovascular and cerebrovascular disease risk assessment were influencing factors of the blood glucose control in diabetic patients（P<0.05）.Among them，the glycemic control rate of the patients with university education and above was 2.531 times higher than that of those without schooling〔95%CI（1.147，5.582）〕；the glycemic control rate of patients in Kunshan was 1.822 times higher than that of patients in Changzhou〔95%CI（1.049，3.167）〕；the glycemic control rates of patients who missed the medication occasionally according to the instructions and took medication strictly according to doctor's orders were 3.363 times〔95%CI（1.314，8.610）〕 and 3.876 times〔95%CI（1.629，9.220）〕 higher than that of those who never took the medicine，respectively；the glycemic control rate of patients with contracted family doctors was 2.466 times higher than that of those without contracted family doctors〔95%CI（1.523，3.991）〕；the glycemic control rate of patients who had received the risk assessment of cardiovascular and cerebrovascular diseases was 2.334 times higher than that of patients who had not receive the risk assessment〔95%CI（1.363，3.999）〕.Patients with contracted family doctors had better medication compliance than those without contracted family doctors，and a higher proportion of receiving the risk assessment of cardiovascular and cerebrovascular diseases（P<0.05）.Conclusion　Primary health care reform measures，such as contracted family doctor services and innovative technologies of Internet plus，have shown the effect in the management of diabetic patients，and they mutually promote each other.The information technology led by grassroots medical staff is more likely to play an important role in the healthcare reform，so it is suggested to further promote it.