Abstract: Objective　To evaluate the application effect of health management model that taking family as units on diabetes.Methods　82 patients,who came from two community health service centers of similar size and scale,and were admitted into Gansu Provincial Hospital due to type 2 diabetes from February to June in 2015 and discharged from the hospital in a stable state of illness,were selected by convenience sampling method.In accordance with the community health service center they belonged to,they were divided into experimental group and control group,and each group had 41 cases with a family group of 58 cases.Patients in two groups received routine health management,including the process of diabetes,clinical manifestations and hazard,tertiary prevention strategies,five indispensable items in the treatment of diabetes,and prevention and treatment of complications;the experimental group adopted synchronous participation mode of family groups,both groups were intervened for 12 months.The self-management skills of patients in two groups and the improvement condition of unhealthy lifestyles of family groups were observed before and after intervention.Results　Before intervention,there were no significant difference in scores of diet control,regular exercise,taking medicine as advised by doctors,foot care,dealing with high and low blood glucose and total scores of patients between two groups（P>0.05）;before intervention,score of self-monitoring of patients in experimental group was significantly lower than that in control group（P<0.05）;after intervention,scores of diet control,regular exercise,taking medicine as advised by doctors,self-monitoring,foot care,dealing with high and low blood glucose and total scores of patients in experimental group were significantly higher than those in control group（P<0.05）.Before intervention,there were no significant difference in uneven intake rate of staple and non-staple food,score of fagerstrom test for nicotine dependence（FTND）,score of alcohol use disorder identification test（AUDIT） and score of physical activities rating scale（PARS-3） of family groups between two groups（P>0.05）;after intervention,there was no significant difference in FTND score of family groups between two groups（P>0.05）;after intervention,the uneven intake rate of staple and AUDIT score of family groups in experimental group were lower than those in control group,while PARS-3 score was higher than that in control group（P<0.05）.Conclusion　Health management model that taking family as units can obviously facilitate the improvement of self-management skills of type 2 diabetes,meanwhile can strengthen concept of prevention and treatment of diabetes of high-risk population and help correct their unhealthy lifestyles,thus reduce occurrence risk of diabetes.

Key words: Diabetes mellitus,type 2, Case management, Treatment outcome

摘要： 目的　探讨以糖尿病家族为单位的健康管理模式应用的效果。方法　采用便利抽样法，选取甘肃省人民医院2015年2—6月，以2型糖尿病收治入院，病情稳定出院且来自两个大小、规模相仿的社区卫生服务中心的患者82例，按照所属社区卫生服务中心分为试验组与对照组，各41例，试验组和对照组家族人群各58例。两组患者均采用常规健康管理，包括糖尿病的进程、临床表现与危害、三级预防策略、糖尿病治疗五驾马车、并发症的预防及处理等，试验组同时采取家族人群同步参与模式，干预时间12个月。观察干预前及干预后，两组患者自我管理能力及家族人群不良生活方式的改善情况。结果　干预前，两组患者饮食控制、规律锻炼、遵医嘱服药、足部护理、处理高低血糖评分及总分比较，差异均无统计学意义（P>0.05）；干预前，试验组患者自我监测评分低于对照组（P<0.05）；干预后，试验组患者饮食控制、规律锻炼、遵医嘱服药、自我监测、足部护理、处理高低血糖评分及总分高于对照组（P<0.05）。干预前，两组家族人群主副食摄入不均率、尼古丁依赖检测量表（FTND）评分、酒精使用障碍筛查量表（AUDIT）评分、体育活动等级量表（PARS-3）评分比较，差异均无统计学意义（P>0.05）；干预后，两组家族人群FTND评分比较，差异无统计学意义（P>0.05）；干预后，试验组家族人群主副食摄入不均率、AUDIT评分低于对照组，PARS-3评分高于对照组（P<0.05）。结论　以糖尿病家族为单位的健康管理模式对2型糖尿病患者自我管理能力提高有明显促进作用，同时还可强化高危人群的糖尿病防治理念，有助于纠正其不良生活方式，从而降低其糖尿病发生风险。

关键词: 糖尿病,2型, 病例管理, 治疗结果