“互联网+”糖尿病三方共管健康管理模式构建与应用研究

目的 构建“互联网+”糖尿病三方共管健康管理模式,并通过在社区患者中应用,评价本模式的管理效果。 方法 通过文献研究、个人深入访谈、专家论证咨询或现场调查等一系列方法建立“互联网+”糖尿病三方共管健康管理操作指南和流程;对实验组的650名糖尿病患者进行为期10个月的健康管理,按照1∶1配比对照组650名患者进行常规管理;从血糖控制、知识掌握、行为改变等方面评价管理效果。 结果 实验组经过10个月的“互联网+”健康管理,患者2周平均自测血糖数从(1.12±0.46)次上升到(2.45±0.65)次,且自测血糖行为明显优于对照组(P<0.001)。实验组中有84%的糖尿病患者能完成了5个以上健康教育课程;患者对糖尿病相关知识掌握率从48%提高到干预后的88%,差异有统计学意义(P<0.001)。有59.8%和68.5%的患者改善了运动和饮食行为;患者的用药依从性从52.1%提高到91.8%。实验组患者在入组时平均空腹血糖和餐后2小时血糖为7.41 mmol/L和10.59 mmol/L下降到管理后的6.47 mmol/L和8.24 mmol/L,血糖控制率从36.15%提高到69.08%,差异有统计学意义(均P<0.001),血糖控制效果明显优于对照组(P<0.05)。 结论 构建成功的“互联网+”糖尿病三方共管健康管理模式对糖尿病患者的管理效果满意,值得在我国的社区糖尿病患者管理中推广应用。 

Construction and application of internet-based combining with patient-family-general practitioner group co-management model for diabetes

Objective To implement and evaluate the effect of internet-based combining with patient-family-general practitioner group Co-management model for diabetes. Methods The management guide and flow chart were set up by series of methods including literature research, personal in-depth interviews, expert consultations and field investigations. A total of 650 patients with diabetes as experimental group were managed by internet-based technology combining with patient-family-general practitioner group Co-management. Another 650 diabetes patients were set as control group according to the 1:1 match, received conventional management. The blood glucose, health behaviors were compared between the two groups to evaluate the effect for 10 months. Results After 10 months intervention, the times of self-test blood glucose in two week in experimental group was significantly increased from 1.12±0.46 to 2.45±0.65, which was better than that of control group(P<0.001). Among the experimental group, 84% of the patients completed more than 5 health education courses. Diabetes knowledge awareness rate was increased from 48% to 88%, the difference was statistically significant(P<0.001). Some patients improved their exercise(59.8%) and diet behaviors(68.5%), and their medication compliance increased from 52.1% to 91.8%. The mean levels of fasting glucose(FBG), 2-hour postprandial blood glucose(2 hPG) of experimental group were significantly reduced from 7.41 mmol/L and 10.59 mmol/L to 6.47 mmol/L and 8.24 mmol/L. The control rate of blood glucose was increased from 36.15% to 69.08%, the difference was statistically significant(all P<0.001).The blood glucose results of experimental group was much better than that in the control group(P<0.05). Conclusion Internet-based combining with patient-family-general practitioner group Co-management model for diabetes is effective. It's worthy of further application and promotion in China to improve the management effect of diabetes.