摘要
目的建立基于互联网的全科．专科合作管理糖尿病的模式，探讨其在社区管理糖尿病患者的效果。方法采用组间对照实验，从上海市五里桥社区已建立健康档案的2型糖尿病人中入选415例，分成联合组和对照组。建立全科．专科联合诊治团队，培训社区医护人员，制订社区药物治疗、患者健康教育和自我管理规范，以及血糖、血压控制目标。对联合组患者在社区定期开展血糖监测，每月由社区团队进行随访，每季度开展健康主题讨论会。在项目启动和观察12个月时，分别测定2组空腹血糖、餐后2h血糖、HbA1C、血压、甘油三酯、总胆固醇、体重指数和腰臀比，计算血糖、血压达标率。对未达标的患者，开展基于互联网的全科．专科视频病例讨论会以及有针对性的专科转诊。同时，问卷了解患者月糖尿病治疗药物费用、糖尿病知识知晓率、健康相关行为，以及对全科一专科合作社区糖尿病管理模式的评价。结果观察12个月时，联合组的空腹血糖、餐后2h血糖、HbA。收缩压和舒张压较基线时有明显下降，且空腹血糖、餐后2h血糖、HbA1C、收缩压显著低于对照组，其达标率也好于对照组（P〈0．05）。与基线比较，观察12个月时联合组的健康知识知晓况状的改善率（29．1％对5．5％）、食用健康食品况状的改善率（9．6％对-10．4％）、按时血糖检测况状的改善率（30．3％对10．8％）、对在社区诊治糖尿病支持况状的改善率（35．7％对9．4％）、对联合管理模式接受况状的改善度（63．8％对17．9％）等均较对照组有明显提升（P〈0．01），且对照组观察12个月时每月降糖药物治疗费用较基线有所增加（32．26元对-3．39元，P〈0．05）。结论基于互联网及全科-专科合作管理糖尿病的模式，在未增加糖尿病药物治疗费用前提下，具有很好帮助患者实现血糖控制、增加健康行为和提升在社区诊治依从性等作用，其在药物治疗、血糖管理、会诊转诊、健康教育和治疗花费等方面的机制值得深入研究。
Objective To assess the effectiveness of tele-medicine and self-management goal（SMG） setting technique used in the diabetes management in the community setting. Methods It is a control-group study. 415 type 2 diabetic residents were recruited from the Shanghai Wuliqiao community based on existing medical records. The subjects were divided into two groups, the study group was cared by general practitioners （GPs） specialists cooperation through the tele-medicine mechanism, the other was a control group. For the study group, a cooperation pathway between community health care centers and general hospitals were established. Standardized training and guidelines were provided to community health workers, regarding the setting of management goals of blood glucose and blood pressure, treatment plan, patient education, and SMG techniques. Fasting blood glucose （ FBG ） and 2 h postprandial blood glucose （2hBG） in the study group were monitored, followed by community health workers visiting monthly with seminars for diabetes education. At the baseline and the 12th month, FBG, 2hBG, HbAlc, blood pressure, triglyceride, total cholesterol, body mass index, waist-hip ratio were determined in each group. A survey was conducted to evaluate the costs of diabetes treatments, the knowledge base related to their disease, lifestyle, and the awareness of the new care model. The rates of achieving the goal of blood glucose, blood pressure, and HbAjc control were calculated. Internet case discussion between GPs-Specialists and referral to certain specialists were implemented when some patients did not reach the control goal. Results By the 12 month follow up, FBG, 2hBG, HbA1C, blood pressure of the study group were lower than the baseline, and as well as the control group with statical significance （P 〈 0.05 ）. There are other improvements ： diabetes knowledge （ 29. 1% vs 5.5 % ）, healthy diet （9.6% vs -10.4% ）, blood glucose monitoring （30.3% vs 10. 8% ）, support for diabetes care in community （35.7% vs 9.4% ）, and the preference of the new model （ 63.8% vs 17.9% ） with statistical significance （ P 〈 O. 01 ）. As for the medical costs, the study group＇s monthly costs were consistently lower than the control＇s. （ -3.39 Yuan vs 32.26 Yuan, P〈0.05）. Conclusions The new diabetes care model based on GPs-Specialists tele-medicine and SMG in community opens the door to the community based care model formulation in regard to the health quality and costs control. The deployment of more technologies and management techniques could be explored further to improve the outcomes of community based chronic disease care model.
出处
《中华内分泌代谢杂志》
CAS
CSCD
北大核心
2012年第4期286-289,共4页
Chinese Journal of Endocrinology and Metabolism
基金
申康课题（SHDCl2007318）
上海市教委重点课题（10ZS74）
作者单位： （赵列宾、陈宇红、董斌、周莹霞、陆骆、宁光）
上海交通大学医学院公共卫生学院（赵列宾、张传政）
五里桥社区卫生服务中心（李昱东、李立强、王志泉）
上海普之康佳园信息科技有限公司（张明延）
Et本泰尔茂公司（张磊、久井良之）
世界健康基金会（肖文慧）
卢湾区卫生局（崔平、赵明瑶、孙海燕、赵丹丹）
复旦大学公共卫生学院（陈英耀）
申康医院发展中心（于广军）Email.zhaoljebin@】26COm
关键词
糖尿病
社区
全科-专科合作
互联网
Diabetes mellitus
Community
GPs-Specialist cooperation
Internet
