上海某社区糖尿病不同干预方式效果比较

目的：通过家庭医生制服务模式运行，探索家庭医生在社区慢性病管理方面的作用和效果。方法：对家庭医生为干预组的糖尿病患者进行家庭健康评估，实施家庭、站点、门诊、病房、转诊“五站式”的连续性疾病管理，借助华东、仁济、同仁等医院医疗资源构建全面技术合作机制、采用个体化治疗方案。结果：通过家庭医生制服务模式在社区糖尿病管理中的运用，干预组患者对糖尿病防治知识知晓度和行为的改变明显高于对照组患者，有显著差异（P〈0．05）；干预组患者的空腹血糖、餐后血糖、总胆固醇、三酰甘油、高密度脂蛋白（HDL）等生化指标较对照组有明显下降趋势，并具有统计学意义。结论：以全科医生为核心的家庭医生制服务模式在社区糖尿病管理中的运用，能有效提高糖尿病患者的依从性及糖尿病管理率和控制率。

Effectiveness comparison of different interventions of diabetes management in one Shanghai community

Objective： To explore the role and effects of family doctors in the community management of chronic disease by family doctor system services mode. Methods： Family doctors conducted family health assessment for the intervention groups and implement the five-stop continuity disease management, including family, site, outpatient service, wards and referral treatment. They also used medical resources in several hospitals to build a comprehensive technical cooperation mechanism. Individualized treatment programs were also used. Results： Patients＇ awareness degree of intervention group in the prevention and control of diabetes knowledge was higher than that of the control group and the same with their behavior. There were significant differences （ P〈O.05 ） .The biochemical parameters of intervention group, including fasting glucose, postprandial glucose, total cholesterol, triglycerides, HDL, got a faster downward trend than those of the control group and the difference between the two groups was statistically significant. Conclusion： General practitioner-focused family doctor system service model effectively improves adherence to diabetes and diabetes management and control rates in community diabetes management.