关键词: 糖尿病, 2型；糖尿病服务包；社区卫生服务；疾病管理

Abstract: Background  The increasing incidence of diabetes and its complications has become a global public health problem，posing a great burden on individuals，families and socio-economic development.The personalized diabetes service package for community residents is conducive to optimal management.Objective  To evaluate the management effect of diabetes service package of Hongshan Street Community in Guangzhou，by comparing its performance with that of national public health service package，providing a reference for the exploration of effective mode of for comprehensive community-based prevention and management of diabetes.Methods  232 patients with stable type 2 diabetes mellitus were selected from 6 residential committees served by Hongshan Street Community Health Center from September 2014 to September 2016.By random number method，they were equally divided into control group and intervention group，receiving the management with national public health service package，and management with diabetes service package of Hongshan Street Community.All of them also received a follow-up lasting for 9 months.The levels and rates of meeting the target objective of laboratory indicators（including glycemic and biochemical indicators，etc.） before and after intervention were compared between the two groups.Results  In the control group and the intervention group，23 and 20 patients were lost to follow-up，and 93 and 96 patients were included in the analysis.There were no significant differences in all indicators before intervention between the two groups（P>0.05）．After intervention，fasting plasma glucose（FPG），2 h postprandial plasma glucose（2 hPG），and glycosylated hemoglobin（HbA1c） of intervention group were lower significantly than those of control group（P<0.05），but systolic blood pressure（SBP），diastolic blood pressure（DBP），body mass index（BMI），waist-hip ratio（WHR），total cholesterol（TC），triglyceride（TG），high-density lipoprotein（HDL），and low-density lipoprotein（LDL） did not（P>0.05）．The rates of meeting the target objective for all indicators were similar in both groups before intervention（P>0.05）．The rates of meeting the target objective for FPG and 2 hPG of intervention group were higher significantly than those of control group（P<0.05），but those for SBP，DBP，HbA1c，TC，TG，HDL and LDL were still similar in both groups after intervention（P>0.05）．Conclusion  Hongshan Street Community diabetes service package has better effect on glycemic control in type 2 diabetes mellitus.It is of great significance to standardize the management of diabetes mellitus and to improve the hierarchical medical system.

Key words: Diabetes mellitus, type 2；Diabetes service package；Community health services；Disease management