多元化管理对血糖不达标糖尿病患者控制效果研究

沈利明  陈华星▲  陆海珠

上海市青浦区白鹤镇社区卫生服务中心，上海201709

[摘要]目的 对血糖控制不达标患者实施多元化管理，为深化社区糖尿病管理提供依据。 方法 通过系统筛选确定人群进行签约管理，以预约门诊、主题活动、家庭指导及定期监测等手段改变患者不良生活习惯和纠正治疗误区。 结果 100例血糖控制不达标患者不良生活方式和生物学指标较管理前有显著提高（不良生活方式比例由81%下降至59%；空腹血糖达标率由2%上升到36%，糖化血红蛋白达标率由9%上升到35%）。 结论 对重点糖尿病患者进行多元化管理可以取得比较明显的效果，是社区糖尿病管理中不可缺少的方法之一。

[关键词] 糖尿病；血糖不达标；多元化

[中图分类号] R587.1   [文献标识码] B   [文章编号] 2095-0616（2014）09-172-03

Control effect of diversified management on diabetes patients with blood glucose not up to standard

SHEN Liming  CHEN Huaxing  LU Haizhu

Baihe Town Community Health Service Center of Qingpu District in Shanghai, Shanghai 201709, China

[Abstract] Objective Through the diversified implementation of diversified management on diabetes patients with blood glucose not up to standard, to provide the basis for the deepening of community diabetes management. Methods To contract and manage the crowd through the systematic screening determine. Outpatient appointment, theme activities, family guidance and regular monitoring, to change the bad habits and correct errors in treatment by. Results 100 diabetes patients with blood glucose not up to standard were significantly improve on bad habits and biological index than before diversified management. (The proportion of bad habits decreased from 81% to 59%; Compliance rate of fasting blood glucose increased from 2% to 36%; Compliance rate of glycosylated hemoglobin increased from 9% to 35%.) Conclusion Diversified management on intensive diabetes patients can obtain obvious effect, which is one of the indispensable methods in the management of diabetes in community.

[Key words] Diabetes mellitus; Blood glucose not up to standard; Diversification

糖尿病是一种常见病、多发病。目前其发病率在我国呈不断上升趋势，正严重威胁着我国人民的身体健康。就2型糖尿病而言，目前上海仍有60%的糖尿病患者血糖控制不达标，在中国仍有超过70%的糖尿病患者血糖控制不理想。分析血糖不达标原因主要包括：遵医行为差、不良生活方式存在、糖尿病知识缺乏、缺乏正规治疗。由于糖尿病目前无法根治，一旦患病，往往终身伴随，各种糖尿病并发症是影响糖尿病患者健康甚至生命的主要原因，因此需要采取各种综合治疗，提高血糖达标率，以减少或延缓并发症的发生。就上海市郊白鹤镇社区近2年加强对血糖不达标糖尿病患者管理的情况报道如下。……