Abstract: Background　Recently，China has been vigorously promoting diabetes prevention and treatment mainly led by primary healthcare institutions.The Notice on Pilot Implementation of Hierarchical Diagnosis and Treatment of Hypertension and Diabetes（hereinafter referred to as the Notice） issued in 2015 clearly put forward that primary healthcare institutions are responsible for initial clinical diagnosis of hypertension and diabetes，and delivering individualized and standardized treatment according to corresponding guidelines and standards.Moreover，the Notice encouraged community health centers to build a regional healthcare consortium with higher-level hospitals，and cooperate with them using a self-developed reasonable collaborative way，to guide the masses to seek diabetes prevention and treatment services in primary care，gradually realizing initial consultation of diabetes in community care and successful bi-directional referrals for diabetes.Objective　To explore the effect of multidisciplinary management on psychosomatic rehabilitation of community-dwelling diabetic patients，enriching the essence of contracted family doctor services.Methods　 A total of 222 diabetic patients who received follow-up management from Taiping Community Health Station and Huiyang Community Health Station of Taicang Economic-technological Development Area Community Health Center were enrolled from January 2017 to January 2018.By use of coin flipping technique，they were divided into the intervention group（n=110） and control group（n=112），treated with 12-month multidisciplinary management，12-month conventional management，respectively.Changes in blood pressure and glycosylated hemoglobin（HbA1c） from baseline to the end of 3，6，and 12 months of management，and those in GLU and lipids（TG，TC，HDL-C，LDL-C） from baseline to the end of 6，and 12 months of management，and the Quality of Life Questionnaire（SF-36）scores in different dimensionsn at baseline and at the end of management were evaluated.Results　Post-intervention status in both groups showed：significant interaction effects produced by the intervention method and time，and significant main effects brought by both intervention method and time on systolic blood pressure（SBP） were observed（P<0.05）．There was no interaction between the intervention method and time on diastolic blood pressure（DBP）（P>0.05）．Intervention time exerted significant main effect on DBP，while intervention method did not（P>0.05）．HbA1c obtained significant main effects produced by intervention method or intervention time（P<0.05），but no obvious interaction effects produced by them（P>0.05）．GLU received significant interaction effects from intervention method and time，and obvious main effects produced by intervention method or time（P<0.05）．Intervention method and time yielded notable main effects（P<0.05） but no interaction effect（P>0.05） on TG.TC received no obvious interaction effect from intervention method and time（P>0.05），but obtained significant main effect from intervention method（P<0.05） instead of intervention time（P>0.05）．Interaction method and time had significant interaction effects on HDL-C（P<0.05）．Intervention method produced significant main effect on HDL-C（P<0.05），but intervention time did not（P>0.05）．Both intervention method and time exerted main effects on LDL-C（P<0.05），but they had no interaction effect on it（P>0.05）．Post-intervention average scores of 4 subscales of SF-36（role limitations due to physical health problems，vitality，social functioning，and mental health） of the intervention group were significantly higher than those of the control group（P<0.05）.Conclusion　12-month multidisciplinary management showed better effect on improving the levels of HbA1c，blood pressure，blood glucose and blood lipids in type 2 diabetic patients than control group.The improvement of physical health problems，vitality，social functioning，and mental health score in SF-36 was better than that in control group.Multidisciplinary management fully mobilizes patients' enthusiasm for treatment in management， so that diabetes mellitus can be well controlled.

Key words: Diabetes mellitus, Community health services, Multidisciplinary joint management, Psychosomatic rehabilitation

摘要： 背景　近年来，国家大力推行以基层医疗卫生机构为主的糖尿病防治工作。2015年，《关于做好高血压、糖尿病分级诊疗试点工作的通知》明确了基层医疗卫生机构负责高血压和糖尿病的临床初步诊断，按照疾病诊疗指南和规范制定个体化、规范化的治疗方案；同时鼓励社区卫生服务中心与上级医院构建医联体，创建合理分工协作机制，引导糖尿病的防治结合和关口前移，逐步实现社区首诊、双向转诊。目的　探讨多学科联合管理模式对社区糖尿病患者心身康复的管理效果，旨在丰富家庭医生签约服务内涵。方法　选取2017年1月—2018年1月在太仓经济开发区社区卫生服务中心下属太平和惠阳两家社区卫生服务站管理随访的2型糖尿病患者222例为研究对象，采用抛硬币法分为干预组（n=110）和对照组（n=112）。干预组采用多学科联合管理模式，对照组采用常规管理模式。比较干预前及干预后3、6、12个月的血压、糖化血红蛋白（HbA1c）；比较干预前及干预后6、12个月的空腹血糖（GLU）、血脂〔三酰甘油（TG）、总胆固醇（TC）、高密度脂蛋白胆固醇（HDL-C）、低密度脂蛋白胆固醇（LDL-C）〕及干预前、干预后12个月的生活质量调查表（SF-36）各维度评分。结果　干预方法和时间在收缩压上存在交互作用（P<0.05），干预方法、时间在收缩压上主效应显著（P<0.05）；干预方法和时间在舒张压上不存在交互作用（P>0.05），干预方法在舒张压上主效应不显著（P>0.05），时间在舒张压上主效应显著（P<0.05）；干预方法和时间在HbA1c上不存在交互作用（P>0.05），干预方法、时间在HbA1c上主效应显著（P<0.05）。干预方法和时间在GLU上存在交互作用（P<0.05），干预方法、时间在GLU上主效应显著（P<0.05）；干预方法和时间在TG上不存在交互作用（P>0.05），干预方法、时间在TG上主效应显著（P<0.05）；干预方法和时间在TC上不存在交互作用（P>0.05），干预方法在TC上主效应显著（P<0.05），时间在TC上主效应不显著（P>0.05）；干预方法和时间在HDL-C上存在交互作用（P<0.05），干预方法在HDL-C上主效应显著（P<0.05），时间在HDL-C上主效应不显著（P>0.05）；干预方法和时间在LDL-C上不存在交互作用（P>0.05），干预方法、时间在LDL-C上主效应显著（P<0.05）。干预后12个月，干预组患者生理职能、生命活力、社会功能、精神健康评分高于对照组（P<0.05）。结论　经多学科联合管理后12个月，糖尿病患者血压、HbA1c、GLU和血脂指标较对照组均有改善，SF-36中生理职能、生命活力、社会功能、精神健康评分的改善好于对照组。多学科联合管理能充分调动患者治疗积极性，使糖尿病得到良好控制。

关键词: 糖尿病, 社区卫生服务, 多学科联合管理, 心身康复