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".

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

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.

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 HbA_1c 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, HbA_1c 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) .

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.

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。

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。

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。

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（HbA_1c）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、HbA_1c达标率、ABC综合达标（HbA_1c、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）。

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。