容桂地区糖尿病社区-医院一体化管理模式的建立与效果研究

目的探讨容桂社区糖尿病社区一医院一体化管理模式的建立与管理效果，为制定本地区糖尿病防治提供依据。方法通过对5582例糖尿病实施了社区一医院一体化管理模式进行规范化管理，并进行一体化管理前后的效果进行评价（糖尿病患者管理率、控制率和糖尿病知识知晓率等）。结果糖尿病患者经过社区一医院一体化管理，社区糖尿病病人对糖尿病及其并发症知识的认识、肥胖、高血压和高血脂与糖尿病的关系及健康生活方式的重要性；病人对糖尿病防治知识、不良生活方式纠正率和血糖自测率；遵医率（病人按时、饮食控制、药物疗法及运动疗法）；以及空腹血糖及餐后2h血糖等指标均优于一体化管理前有明显改善，管理前后差异有统计学意义（P〈0．01）。结论糖尿病社区一医院一体化管理，充分发挥了综合性医院的技术优势和社区医疗中心的地理优势，优化资源配置，形成优势互补，有效整合医疗卫生资源，提高了糖尿病管理的成本效益，对糖尿病的早期发现、早期治疗，有效控制扣减少并发症的发生起到了积极的作用，减轻了病人的医疗负担．为本地区社区糖尿病防治综合管理模式的提出了新思路。

Study on Effect of Community-Hospital Integrated Management Model on Diabetes Mellitus in Ronggui District Foshan City

bstract OBJECTIVE To study the effect of community-hospital integrated management model on patients with diabetes mellitus in Ronggui District, and provide proofs to the prevement and treat of diabetes in local area. METHODS 5 582patients suffered diabetes were under standardized management with community-hospital integrated model, to evaluate the effect premanagement and postmanagement（the rate of management, control rate, and the rate of knowledge about diabetes）. RESULTS Patients suffered diabetes know more knowledge about the risk factors such as adiposity, hypertesion, hyperlipemia to diabetes and the importance of healthy life style after be procdued by the mangagement of community-hospital integrated model, patients know more about the disease and more energetic to correct the mistake in live, more coordinatge to the doctor（diet control, drug treatment, kinesipathy, produce important significance to early detection, early treatment, effect congtrol, reduce the complication of diabetes, the value of fast blooding-glucose and Post-prandial glycemia is more improvement than before management by the mangagement of community-hospital integrated model. CONCLUSION Mangagement of community-hospital integrated model play fully importmant function of integrity hospital and the geographical advantage, improve the cost-effective and play great function in early detection, early treatment, effect congtrol and reduce the complication of diabetes, it reduced the medical burden and provided a new mentality to prevement and treat of diabetes in local area.