分阶段达标管理模式对社区老年2型糖尿病患者干预效果分析

Intervention Effect of Staged Target Management Model on Elderly Patients with Type 2 Diabetes in Community

中文关键词: 分阶段达标管理模式  糖尿病  2型  疾病管理

英文关键词: staged target management model  diabetes  type 2  disease management

中文摘要:

      目的 探讨“5+1”分阶段达标管理模式(“5+1”模式)对社区老年2型糖尿病患者血糖、血压和血脂的干预效果.方法 从南京市鼓楼区10个社区卫生服务中心选取自2013年1月起纳入管理的老年2型糖尿病患者3 650例,从中筛选含自纳入起3～6个月、6～12个月及末次随访资料患者1 658例.所有患者均采用“5+1”模式进行随访干预,分别收集患者管理前、基线、第1次随访(3～6个月)、第2次随访(6～ 12个月)及末次随访资料,包括患者一般临床资料、各项代谢指标及相关糖尿病并发症检查等.结果 患者末次随访的糖化血红蛋白(HbA1c)、空腹血糖(FPG)、餐后2h血糖(2hPG)、收缩压(SBP)、舒张压(DBP)、总胆固醇(TC)、三酰甘油(TG)、低密度脂蛋白胆固醇(LDL-C)比基线降低,高密度脂蛋白胆固醇(HDL-C)比基线升高,差异均有统计学意义(P均＜0.05);末次随访的血糖、血压、血脂单项达标率及3项综合达标率与基线比较均显著升高,差异均有统计学意义(HbA1c达标率从53.00％升高至64.23％,血压达标率从67.80％升高至85.17％,LDL-C达标率从44.99％升高至51.77％,3项达标率从18.33％升高至29.62％,P均＜0.01).结论 “5+1”模式能提高社区老年2型糖尿病患者的血糖、血脂和血压达标率,值得被广泛使用.

英文摘要:

      Objective To explore the intervention effect of "5+ 1" staged target management model on blood glucose,blood pressure and blood lipid of the elderly patients with type 2 diabetes in community.Methods 3650 elderly with type 2 diabetes under the management of 10 community health service centers of Gulou District,Nanjing since Jan.,2013 were enrolled,out of whom,1658 patients with the follow-up data within 3 to 6 months after listed in the management,the data within 6 to 12 months and the data of latest follow-up were selected;follow-up intervention of "5 + 1" staged target management model had been performed on all the patients;the data of the patients before being listed in the management,at base-line,the first follow-up (within 3 to 6 months),the second follow-up (within 6 to 12 months) and the latest follow-up were collected,including the general clinical information,metabolism index and the examinations of complications related to diabetes.Results The levels of HbA1c,FPG,2hPG,systolic pressure,diastolic pressure,TC,TG,LDL-C of the patients in the latest follow-up were all higher than those at base-line with statistical difference (P＜0.05);single compliance rate of blood glucose,blood pressure and blood lipid was much higher than that at base-line as well as the general compliance rate of the 3 items,the difference was of statistical significance (P＜ 0.01).Conclusions Intervention with "5 + 1" staged target management model can lift the compliance rate of blood glucose,blood lipid and blood pressure of the elderly patients with type 2 diabetes in community,which is worthy of wider performance.