医院-社区-家庭一体化管理模式对 糖尿病患者的应用价值

黄淑娇¹  温卫东¹   黎辉敏²

（1.龙江社区卫生服务中心，广东  佛山，528318；2.龙江西海社区卫生服务站，广东  佛山，528318）

中图分类号：R255.4     文献标识码：A    文章编号：1674-7860（2016）09-0059-03   证型：DGB

【摘  要】目的：分析护理干预对2型糖尿病患者的可行性。方法：选取顺德区龙江社区病程在1年以上的依从性不佳的老年糖尿病患者150例，按照双盲随机数字表法将150例患者随机分为两组，分为对照组和管理组。其中对照组患者实施常规管理。管理组患者实施医院—社区健康服务中心—家庭一体化管理模式。两组均进行为期1年的干预。观察2年后两组患者：生命质量的变化、空腹血糖（FBG）、餐后2 h血糖（2 h PBG）和糖化血红蛋白（HbA1c）的变化、发病次数、住院次数、住院天数、医疗费用、生活饮食习惯、自我血糖监测、遵医嘱用药行为、运动行为依从性。结果：管理组患者发病次数、住院次数、住院天数、医疗费用明显少于对照组，组间经t检验有显著的统计学差异（P＜0.05）。管理组干预后生命质量、FBG、2 h PBG和HbA1c明显优于对照组，组间经t检验有显著的统计学差异（P＜0.05）。管理组生活饮食习惯、自我血糖监测、遵医嘱用药行为、运动行为依从性明显高于对照组，组间经x²检验有显著的统计学差异（P＜0.05）。结论：医院—社区—家庭一体化管理模式对糖尿病患者的应用价值高，可有效提升患者遵医行为，有助于控制患者发病率，减少住院率，减轻医疗负担，还有助于改善患者血糖水平，提升其生命质量，值得推广。

【关键词】医院—社区—家庭一体化管理模式；糖尿病患者；应用价值

【Abstract】Objective:To analyze the feasibility of nursingintervention on patients with type 2 diabetes. Methods:150 cases with type 2 diabetes in Longjiang community of ShundeDistrict were patients with poor compliance and their course of diseasewas more than one year, the patients were randomly divided into the controlgroup and the management group. The control group received routine managementwhile the management group received hospital-community-family integratedmanagement model, the intervention lasted one year and the following factors ofpatients in two groups were observed two years later: changes in quality oflife, fasting blood glucose (FBG), postprandial 2 hours blood glucose (2hPBG)and glycosylated hemoglobin (HbA1c)changes, the number of onset, frequency of hospitalization, length of stay,medical expenses, living habits, self monitoring of blood glucose, prescribedmedication behavior, behavior compliance. Results:The number of onset, frequency of hospitalization, length of stayand medical expenses of the management group were significantly less than thoseof the control group; the differences between two groups were statisticallysignificant by t test (P<0.05). After intervention, thequality of life, FBG, 2hPBG and HbA1c of the management group were significantly betterthan those of the control group, the differences between two groups werestatistically significant by t test (P<0.05). The living habits, selfmonitoring of blood glucose, prescribed medication behavior, behaviorcompliance of the management group were significantly better than those of thecontrol group, the differences between two groups were statisticallysignificant by x² test (P<0.05). Conclusion:Hospital-community-family integrated management model had high applicationvalue on patients with type 2 diabetes, it could improve patients’ behaviorcompliance effectively, and decrease hospitalization rate and relieve medicalburden in addition to decrease patients’ blood sugar level and improve theirlife quality, therefore, it was worth popularizing.

【Keywords】Hospital-community-family integratedmanagement model; Patients with diabetes; Application value

doi:10.3969/j.issn.1674-7860.2016.09.027

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