Abstract: Objective　To evaluate the effectiveness of a family doctor-led self-management support intervention among type 2 diabetic patients living at the rural–urban fringe.First-hand evidence was gathered to help the exploration of appropriate management model for type 2 diabetes mellitus.Methods　The enrolled participants were sampled from the type 2 diabetic patients who received treatment from Nanhai Shishan Community Health Center in Foshan between 2016 and 2017.A total of 342 cases were included.They were assigned to the intervention group (n=171) and control group (n=171) with an allocation ratio of 1：1 by computational random number generators.Both groups received the usual antidiabetic treatment and diabetes management，the intervention group additionally received a responsible intervention led by the family doctor team.The intention to treat analysis was used to evaluate the changes in outcomes including hemoglobin A1c (HbA1c)，blood pressure (BP)，lipid profiles，body mass index (BMI)，lifestyle behaviors，and self-rated efficacy between the two groups at 1-year follow up.Results　The levels of mean HbA1c，systolic blood pressure (SBP) and diastolic blood pressure (DBP)，total cholesterol，low-density lipoprotein cholesterol，high-density lipoprotein cholesterol，triglyceride and BMI were similar in both groups at baseline as well as at 1-year follow up，as were the rates of mastering the method for self-monitoring of blood glucose，having foot care regularly，frequently smoking，frequently drinking，taking antidiabetic drugs on schedule and at the proper dose(P>0.05).Moreover，there were no significant differences in the self-rated mean scores of eating habit，exercise habit，taking antidiabetic drugs on schedule and at the proper dose，having foot care regularly and glycemic control between the two groups at baseline and 1-year follow-up (P>0.05).Conclusion　The family doctor-led self-management support intervention seemed to be ineffective in improving the levels of HbA1c，BP，lipid profiles，lifestyle behaviors and self-rated efficacy among type 2 diabetic patients living at the rural–urban fringe.Further exploration and validation of diabetic management models are needed for improvement.

摘要： 目的　了解城乡结合地区2型糖尿病患者实施基于家庭医生服务的自我管理的效果，并为探索适宜推广的糖尿病管理模式提供证据。方法　以2016—2017年在佛山市南海区狮山镇社区卫生服务中心就诊的2型糖尿病患者作为研究对象，共纳入342例患者，采用计算机随机数字法将符合入选标准的糖尿病患者按照1∶1分为对照组（n=171）和干预组（n=171）。对照组采用现行糖尿病常规治疗和管理措施；干预组在对照组治疗的基础上，实施家庭医生团队责任制管理。采用意向性分析比较两组基线及随访1年时糖化血红蛋白、血压、血脂、体质指数的变化、生活行为方式及自我评价效能。结果　基线及随访1年时两组患者糖化血红蛋白、收缩压、舒张压、总胆固醇、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇、三酰甘油、体质指数比较，差异均无统计学意义（P>0.05）。基线时及随访1年时两组患者掌握血糖自测方法、定期进行足部护理、经常吸烟、经常饮酒、按时按量服药比例比较，差异均无统计学意义（P>0.05）。基线时及随访1年时两组患者饮食、运动、药物服用、足部护理、血糖控制评分比较，差异均无统计学意义（P>0.05）。结论　在城乡结合地区，基于家庭医生服务的自我管理对2型糖尿病患者的糖化血红蛋白、血压、血脂、主要生活行为方式及自我评价效能指标改善并不明显，适宜推广的糖尿病管理模式仍需进一步探索及验证。

关键词: 糖尿病, 2型；全科医生；疾病管理；随机对照试验