关键词: 高血压, 糖尿病, 全程照护, 三师共管

Abstract: Objective　To analyze the theoretical characteristics and performance of specialty physician-general practitioner-health manager management for members of Diabetes Network and Hypertension Network from Xiamen.Methods　According to the inclusion criteria of Hypertension Network and Diabetes Network，we enrolled 845 cases of hypertension and 787 cases of diabetes from Xiamen Siming District Jialian Street from July 2015 to July 2016.All of them received 1-year intensive，full-range and comprehensive interventions codelivered by specialty physicians，general practitioners and health managers.The evaluators for this management are BMI，waist circumference，and the control rates of systolic blood pressure（SBP），diastolic blood pressure（DBP），fasting plasma glucose（FPG），total cholesterol（TC），triacylglycerol（TG），low-density lipoprotein cholesterol（LDL-C），high-density lipoprotein cholesterol（HDL-C），urine microalbumin and glycosylated hemoglobin（HbA1c） at the end of 1-year intervention.Results　At the end of 1-year management，for the hypertensive participants，compared with baseline，the control rates of SBP，DBP，TC，TG，HDL-C，and urine microalbumin increased significantly but the control rate of FPG decreased obviously（P<0.05），and BMI，waistline and control rates of LDL-C changed a little（P>0.05）；for the diabetic participants，compared with the baseline，the control rates for SBP，DBP，FBG，TC，TG，LDL-C，HDL-C and urine microalbumin improved significantly（P<0.05），while BMI，waistline and control rates of HbA1c changed slightly（P>0.05）.Conclusion　Specialty physician-general practitioner-health manager management can increase the control rates for SBP/DBP，FPG，blood fat，as well as urine microalbumin，showing its significant management effect on both hypertension and diabetes.

Key words: Hypertension, Diabetes mellitus, Whole-care, Specialty physician-general practitioner-health manager management