糖尿病社区管理优化路径初探

目的探讨糖尿病社区管理优化路径。方法从体检服务、巡诊服务和健教服务三个方面提出糖尿病社区管理优化路径,通过观察A社区及B社区,比较两者的年就诊人次、血糖及血脂水平、糖尿病知识知晓率、生活方式及治疗依从性改善情况。结果 1观察组社区卫生服务机构年就诊人次较对照组明显增加,但二级及以上医疗机构年就诊人次及高危病人年就诊人次数较对照组减少。2观察组空腹血糖、甘油三酯水平均明显低于对照组（P〈0.05）。3在糖尿病知识知晓率方面,关于血糖达标值、糖尿病饮食及慢性并发症、血糖监测,观察组均优于对照组（P〈0.05）;关于生活方式及治疗依从性的改善上,在血糖监测、控制饮食及按医嘱服药上观察组均明显好于对照组（P〈0.05）。结论通过糖尿病社区管理优化路径,提高了糖尿病患者对疾病的认知水平,形成积极的态度和健康的行为,最终有利于疾病的控制。

Explore on optimum pathway of community based management for diabetes

Objective To investigate optimum pathway of community based management for diabetes. Methods The optimum pathway was based on service of health examination, clinical follow-up, and health education. Between A and B community based management,we compared the difference in frequency of doctors＇ office visiting in one year, fasting blood glucose and blood fat, the diabetes knowledge, improvement of life style and patient＇s willingness. Results 1The frequency of doctors＇ office visiting in one year in observation group were significantly higher than that of the control group, but were lower than control group in over Second-class Hospital and high-risk patients. 2The fasting blood glucose and blood fat in observation group were significantly lower than that of the control group（P〈0.05）. 3The awareness rate about the blood glucose level, diabetes diet,chronic complications and blood sugar monitoring in in observation group were significantly higher than control group（P〈0.05）;In improvement of life style and patient＇s willingness,the observation group was better than control group of blood checks,diet control and medication（P〈0.05）. Conclusion Because of the optimum pathway of community based management for diabetes,the diabetes patient has more knowledge in diabetes, positive attitude and healthy behavior,so at last, it is good for treatment.