Abstract: Objective　To evaluate the intervention effect of diseases management mode of community management and self-management on compliance and quality of life in elderly patients with type 2 diabetes after discharge.Methods　A total of 200 patients with type 2 diabetes who were discharged from the Department of General Medical，the First Hospital of Qinhuangdao from August 2015 to July 2016 were selected as the study subjects.Random number table was used to divide patients into intervention group （100 cases） and control group （100 cases） in the randomized controlled trial.For the intervention group，community management-self-management intervention was adopted by setting up regular out-patient or home-based follow-ups，providing medication adjustment，patient and family counseling and other services in community health service centers; patients received face-to-face health education before discharge，and self-management training once a month during follow-ups.Patients in the control group were only given routine guidance at discharge.Baseline data of patients were collected and one clinical follow-up 12 months after discharge was conducted to understand drug use，clinical index of patients.We used Diabetes Knowledge Test （DKT） to evaluate diabetes knowledge，Revised Summary of Diabetes Self-Care Activities （SDSCA） Scale to assess self-care ability，and Diabetes Specific Quality of Life （DSQL） Scale to evaluate quality of life.Results　In the control group，3 patients （3.0%） lost contact after discharge，and 3 patients （3.0%） died during the follow-up.In the intervention group，1 patients （1.0%） gave up halfway because of moving away，and 1 patients （1.0%） died during the follow-up.At the end of the follow-up，the usage rate of aspirin /clopidogrel，and statins in the intervention group was higher than that in the control group （P<0.05）.The usage rate of angiotensin converting enzyme inhibitor（ACEI）/angiotensin Ⅱ receptor antagonist（ARB） in the intervention group was higher than that in the control group （P<0.05）.Body mass index （BMI），glycosylated hemoglobin and low density lipoprotein cholesterol （LDL-C） in intervention group were lower than those in control group（P<0.05）.The score of DKT in the intervention group was higher than that in the control group（P<0.05）.Scores of diet，blood-glucose testing，foot care in intervention group were higher than those in control group（P<0.05）.The number of smokers in intervention group was lower than that in the control group（P<0.05）.The physiological function，mental health，treatment and total score of intervention group were lower than those of control group （P<0.05）.Conclusion　Diseases management mode of combining community management with self-management can significantly improve the treatment compliance，self-care ability，clinic index and quality of life of elderly patients with type 2 diabetes.

Key words: Diabetes mellitus, type 2, Disease management, Self-management, Community health services, Aged, Adherence, Quality of life

摘要： 目的　评估社区管理-自我管理相结合的疾病管理模式对出院老年2型糖尿病患者服药依从性及生活质量的干预效果。方法　顺序入选2015年8月—2016年7月于秦皇岛市第一医院全科医疗科出院的2型糖尿病患者200例。采用随机对照临床研究方法，根据随机数字表将患者分为干预组（100例）和对照组（100例）。干预组采取社区管理-自我管理干预，由社区卫生服务中心进行定期的门诊或上门随访，提供药物治疗调整、患者和家庭成员咨询等服务；出院前患者接受当面的健康教育，出院后每月1次上门随访时对患者进行自我管理培训。对照组患者仅出院时接受常规出院指导。收集患者基线资料，于12个月后进行1次临床随访，了解患者药物使用情况、临床指标，使用《糖尿病知识测试问卷》（DKT）评估糖尿病知识，使用《改良的糖尿病自护行为量表》评估自我管理能力，使用《糖尿病患者生活质量特异性量表》（DSQL）评估生活质量。结果　对照组3例（3.0%）患者因出院后失去联系失访，3例（3.0%）患者随访过程中死亡。干预组1例（1.0%）患者由于搬离原住址而中途放弃，1例（1.0%）患者随访过程中死亡。随访结束时，干预组阿司匹林或氯吡格雷使用率、他汀类药物使用率均高于对照组；干预组血管紧张素转化酶抑制剂（ACEI）/血管紧张素Ⅱ受体拮抗剂（ARB）使用率高于对照组；干预组体质指数（BMI）、糖化血红蛋白、低密度脂蛋白胆固醇（LDL-C）均低于对照组；干预组DKT评分高于对照组；干预组具体饮食、血糖监测、足部护理评分均高于对照组，每日吸烟量少于对照组；干预组生理功能、心理精神、治疗方面评分及总分均低于对照组（P<0.05）。结论　社区管理-自我管理相结合的疾病管理模式可显著改善老年2型糖尿病患者的服药依从性，提高自我护理能力，改善临床指标和生活质量。

关键词: 糖尿病, 2型；疾病管理；自我管理；社区卫生服务；老年人；依从性；生活质量