上海市青浦区社区糖尿病患者积分制管理效果分析

郭晓虎; 叶开友; 杨惠芬; 白慧芝; 王森; 吴周理; 徐瑞芳

doi:10.19428/j.cnki.sjpm.2019.19261

上海市青浦区社区糖尿病患者积分制管理效果分析

Effect analysis on integral system intervention for management of community diabetics in Qingpu District of Shanghai

摘要

摘要:
目的通过分析青浦区糖尿病积分制管理开展前后糖尿病患者管理的指标变化，探索糖尿病管理新模式的效果。
方法对2016年2月起开展积分制管理试点的徐泾镇和朱家角镇在管的糖尿病确诊患者主动参与管理数进行分析，对参加签约积分制管理并规范随访的824名确诊的糖尿病患者作为血糖和糖化血红蛋白变化的重点研究对象，对2年管理前后血糖检测率和糖化血红蛋白检测率进行比较。
结果积分制管理后主动参与糖尿病自我管理患者从2 182人增加至3 274人，血糖检测率从管理前56.74%增加至76.27%，糖化血红蛋白检测率从管理前的0.73%上升至管理后的57.57%。824名参加积分制规范化管理的患者的空腹血糖均值从管理前的8.196 mmol/L下降至管理后的7.745 mmol/L，差异有统计学意义(t=4.904, P＜0.01)，血糖控制率从35.9%上升至40.93%，差异有统计学意义(χ²=39.782，P＜0.01)；糖化血红蛋白的控制率从管理前的39.80%上升至管理后的45.99%，差异有统计学意义(χ²=6.193，P＜0.01)。
结论积分制管理模式能提升糖尿病患者主动参与自我健康管理的积极性，有效提高患者血糖和糖化血红蛋白的控制水平，有利于开展糖尿病管理工作，可以予以推广。

Abstract:
ObjectiveTo explore the effect of a new diabetes management model by analyzing the changes of diabetes management indicators before and after the implementation of the Qingpu District Diabetes Score System.
MethodsA series of diabetics were studied who actively participated in the anaysis in Xujing Town and Zhujiajiao Town, where pilot projects of integrated system management had been carried out since February 2016.The series of 824 diagnosed diabetics were as focus subjects, who signed a contract to participate in the integrated system management and the standardized follow-up.They were investigated and studied for the variation of their blood glucose and glycosylated hemoglobin, in comparison with those obtained 2 years previously before and after the management.
ResultsAfter the integral system management was carried out, the number of active participants in self-management of diabetes increased from 2 182 to 3 274, the blood sugar detection rate increased from 56.74% to 76.27%, and the glycosylated hemoglobin detection rate increased from 0.73% before the management to 57.57% after the management.The mean fasting blood sugar of the 824 patients who participated in the standardized management of integral system decreased from 8.196 mmol/L before management to 7.745 mmol/L after management.The difference was statistically significant (t=4.904, P < 0.01), and the control rate of blood sugar increased from 35.9% to 40.93%.The difference was statistically significant (χ²=39.782, P < 0.01).The control rate increased from 39.80% before management to 45.99% after management, and the difference was statistically significant (χ²=6.193, P < 0.01).
ConclusionThe integral system management model can enhance the initiative of diabetic patients to participate in self-health management, effectively improve the control level of blood sugar and glycosylation, and is conducive to the development of diabetes management, which can be generalized.

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