中国全科医学 ›› 2023, Vol. 26 ›› Issue (34): 4308-4314.DOI: 10.12114/j.issn.1007-9572.2022.0562

• 论著·社区糖尿病管理研究 • 上一篇    下一篇

基于"全专精准管理"的糖尿病"1358模式"对社区糖尿病患者的管理效果研究

姚裕忠1, 马晓骏2,*(), 宋懽1, 钟瑜3   

  1. 1.200082 上海市虹口区北外滩街道社区卫生服务中心全科医学科
    2.200082 上海市虹口区北外滩街道社区卫生服务中心行政科
    3.200082 上海市虹口区北外滩街道社区卫生服务中心社区科
  • 收稿日期:2022-09-29 修回日期:2023-07-16 出版日期:2023-12-05 发布日期:2023-08-03
  • 通讯作者: 马晓骏

  • 作者贡献:姚裕忠负责检索文献、提出研究思路、设计研究方案、申请项目并负责研究管理,参加辖区内糖尿病骨干医师导师制培养、糖尿病"全专"门诊建设,提出糖尿病"1358模式"并开展糖尿病"全专精准管理",收集归纳糖尿病案例,负责论文撰写并定稿,对文章负责;马晓骏对研究提出指导意见,提出"全专精准管理"思路并指导组织实施,对"1358模式"建设给予资源及专业等方面支持,对研究方案进行修改和完善,督导研究的实施与开展,指导论文修改;宋懽收集归纳糖尿病案例及相关数据,参加辖区内糖尿病骨干医师导师制培养,参与糖尿病"全专"门诊、糖尿病"1358模式"的建设与实施;钟瑜收集并分析糖尿病"全专"管理案例,开展调查与收集数据,负责糖尿病健康管理及相关数据质控,协调实施社区糖尿病健康管理与随访。
  • 基金资助:
    上海市虹口区卫生健康委医学科研课题(1901-05)

The Management Effect of Diabetes "1358 model" on Community Diabetes Patients Based on "Precision Management Combining General Care and Specialty Care"

YAO Yuzhong1, MA Xiaojun2,*(), SONG Huan1, ZHONG Yu3   

  1. 1. General Practice Department, Shanghai Hongkou District North Bund Street Community Health Service Center, Shanghai 200082, China
    2. Administration Section, Shanghai Hongkou District North Bund Street Community Health Service Center, Shanghai 200082, China
    3. Community Medicine, Shanghai Hongkou District North Bund Street Community Health Service Center, Shanghai 200082, China
  • Received:2022-09-29 Revised:2023-07-16 Published:2023-12-05 Online:2023-08-03
  • Contact: MA Xiaojun

摘要: 背景 社区糖尿病诊治能力欠佳、并发症筛查率低、血糖规范监测率低、血糖达标率低等难点问题是全科医生在开展糖尿病患者管理时需着重思考和破解的问题。让全科医生成为全科中的专科医生,实现"全专精准管理",需探索、创新糖尿病社区规范化管理模式。 目的 了解基于"全专精准管理"的糖尿病"1358模式"对社区糖尿病患者的管理效果。 方法 以2020年5—7月到上海市虹口区北外滩街道社区卫生服务中心门诊就诊且已与本社区全科医生签约的212例糖尿病患者为研究对象,采用随机数字表法将其分为对照组106例和干预组106例。对照组患者接受常规随访管理,干预组患者接受基于"全专精准管理"的糖尿病"1358模式"。干预1年后,比较两组患者的糖尿病认知和行为水平、关键指标达标情况及在社区卫生服务中心就诊的体验。 结果 干预前,两组患者的糖尿病管理相关认知和行为、关键指标达标率比较,差异无统计学意义(P>0.05)。干预后,干预组1个月内空腹血糖(FPG)监测、1个月内餐后2 h血糖(2 hPG)监测、1个月内血糖综合监测、6个月内糖化血红蛋白(HbA1c)监测、开展自我血糖监测、记录血糖日记、规范用药、遵医嘱饮食、1年内周围血管并发症筛查、1年内尿白蛋白/肌酐筛查、1年内颈动脉斑块筛查、1年内眼底筛查情况优于对照组,差异有统计学意义(P<0.05);但两组规律运动、每周足部检查情况比较,差异无统计学意义(P>0.05)。干预后,干预组患者FPG达标率、HbA1c达标率、ABC综合达标(HbA1c、血压、总胆固醇均达标)率高于对照组,差异有统计学意义(P<0.05);但两组2 hPG达标率比较,差异无统计学意义(P<0.05)。干预组认为社区诊疗能力良好、社区药物基本满足需求、社区具备血糖相关指标检测设备、社区能解决基本健康问题、社区能开展并发症筛查、社区专病咨询指导方便的患者比例高于对照组,差异有统计学意义(P<0.05)。 结论 基于"全专精准管理"的糖尿病"1358模式"在增强患者健康信念、规范患者血糖监测行为、提高患者关键指标达标率、提升患者社区就诊体验方面具有积极意义,可在社区推广应用。该模式或可突破社区糖尿病专科资源不足的瓶颈,进一步提升社区全科医生的糖尿病专病管理水平与服务内涵。

关键词: 糖尿病, 健康管理, 社区卫生服务, 健康信念, 管理模式, 治疗结果

Abstract:

Background

Difficult problems such as poor diagnosis and treatment capacity of diabetes in the community, low screening rate of complications, low standardized monitoring rate of blood glucose, and low rate of blood glucose compliance are the problems that general practitioners need to think about and solve when carrying out management of diabetes patients. It is necessary to explore and innovate the standardized management mode of diabetes in the community for making general practitioners become specialists in the general practice and achieve "precision management combining general care and specialty care".

Objective

To understand the management effect of diabetes "1358 model" on community diabetes patients based on "precision management combining general care and specialty care".

Methods

A total of 212 patients with diabetes who visited the outpatient clinic at the Hongkou District North Bund Street Community Health Service Center from May to July 2020 and had signed a contract with the community general practitioner were selected as the research subjects and divided into 106 cases in the control group and 106 cases in the intervention group by the random number table method. The patients in the control group received routine follow-up management, and the patients in the intervention group received the "1358 model" of diabetes based on "precision management combining general care and specialty care". One year after the intervention, the cognitive and behavioral levels of diabetes, the attainment of key indicators and the experience of visiting community health centers were compared between the two groups.

Results

There was no statistically significant difference in the cognition and behavior related to diabetes management and the attainment rate of key indicators between the two groups (P>0.05). After intervention, the proportions of patients in the intervention group who monitored FPG within 1 month, monitored 2 hPG within 1 month, carried out comprehensive blood glucose monitoring within 1 month, monitored HbA1c within 6 months, carried out self-monitoring of blood glucose, recorded a blood glucose diary, standardized the use of medication, followed the doctor's advice on diet, screened for peripheral vascular complications within 1 year, screened for urinary albumin/creatinine within 1 year, screened for carotid artery plaques within 1 year, screened for the inner ocular fundus within 1 year were higher than those of the control group, and the difference was statistically significant (P<0.05) ; however, there was no significant difference in the proportions of patients with regular exercise and weekly foot examination between the two groups (P>0.05). After the intervention, the rates of FPG attainment, HbA1c attainment and ABC composite attainment of patients in the intervention group was higher than those of the control group, and the difference was statistically significant (P<0.05) ; however, there was no statistically significant difference in the 2 hPG attainment rate between the two groups (P<0.05). The proportions of patients who thought that the community diagnosis and treatment capacity was good, the community drugs basically met the demand, the community had testing equipment for blood glucose-related indexes, the community could solve the basic health problems, the community could carry out screening for complications, the community consultation and guidance for specialized diseases was convenient in the intervention group were higher than those of the control group, and the difference was statistically significant (P<0.05) .

Conclusion

The "1358 model" of diabetes based on "precision management combining general care and specialty care" is of positive significance in promoting and improving patients' health beliefs, standardizing blood glucose monitoring behavior, improving the rate of compliance with key indicators, and enhancing community medical experience, which can be promoted and applied in the community. This model may break through the bottleneck of insufficient resources of diabetes specialty in the community, and further improve the management level and service connotation of diabetes specialty of general practitioners.

Key words: Diabetes, Health management, Community health services, Health beliefs, Management mode, Treatment outcomes