【作者】 刘颖；

【导师】 杜亚平；

【作者基本信息】 浙江大学 ， 全科医学， 2011， 硕士

【摘要】 研究背景近20年来,我国糖尿病的患病率迅速增长。2010年,我国糖尿病患者人数超过9200万,已成为全球糖尿病患者人数最多的国家。因糖尿病病程长、并发症多、致残率高等原因,给个人、家庭和国家带来极大的负担,已成为重要的公共卫生问题。因此,如何有效控制和管理糖尿病,是我国遏待解决的重要问题。上个世纪末本世纪初,我国的社区卫生服务事业蓬勃发展。虽然许多社区卫生服务机构已经开始对糖尿病进行管理,但其无论是在管理内容、管理形式以及管理程序上有着很大的差别,我国尚无统一规范的糖尿病社区管理模式。各地区卫生部门在糖尿病社区管理的探索过程中,自拟糖尿病管理模式内容,而社区卫生服务机构则在各地政府要求的基础上自行摸索不同的糖尿病管理模式。整体而言,我国社区糖尿病管理工作还处于起步状态,缺乏一套行之有效的管理模式。国内外大量的经验表明,依托社区开展糖尿病的防治工作是最有效的。尽管,我国社区糖尿病管理尚处于初始阶段,存在很多问题,但以社区卫生服务作为工作平台是糖尿病综合防治的必然趋势,因此开展糖尿病社区规范化管理是十分必要的。研究目的通过对浙江省杭州市内进行糖尿病患者规范化管理的社区(浙大御跸社区)进行调查研究,总结其管理模式并分析管理效果,以及在浙江省内其他地区推广应用的效果。在此基础上,对糖尿病患者社区规范化管理模式进行初步的探讨,为社区开展糖尿病管理工作提供参考,为我国慢性病的社区管理提供借鉴。研究方法1.文献研究法检索和查阅国内外相关的文献资料,收集有关慢性病社区规范化管理的相关研究内容(尤其是糖尿病),了解关于国内外慢性病管理模式(尤其是糖尿病管理)的相关研究、经验,及其效果,并熟悉我国糖尿病管理研究现状、相关政策,以及目前糖尿病社区管理实施情况。2.抽样方法(1)目的抽样：从浙江省杭州市区内抽取进行糖尿病患者规范化管理的社区为本研究的研究对象,同时选取与该社区基本情况类似未进行糖尿病患者规范化管理的社区为对照组。(2)整群抽样：搜集选取的两个社区中进行糖尿病规范化管理的所有患者的信息资料,比较分析两种不同模式管理的效果。(3)简单随机抽样：从进行糖尿病社区规范化管理推广的30多个慢性病管理基地中,抽取四个社区为研究对象。3.访谈法通过对社区卫生服务机构医护人员多次访谈,了解他们对糖尿病社区管理采取的具体措施和经验方法。4.现场调研或电话(网络调查)通过现场调研,搜集进行规范化管理社区(浙大御跸社区)的糖尿病患者和未进行规范化管理社区(与浙大社区基本情况类似未进行规范化管理的社区)的糖尿病患者的一般信息资料以及随访资料。选择浙江省内进行糖尿病规范化管理推广应用的四个具有代表性的社区(杭州天水武林社区、金华义乌北苑社区、温州乐清向阳社区、金华永康芝英社区)进行调查,通过现场调查或电话(网络)调查的方法对这四个社区的人口组成、团队组建情况、糖尿病管理情况、居民慢性病知识知晓率、居民对社区卫生服务的满意度、健康教育开展情况等。研究结果1、糖尿病社区规范化管理(1)糖尿病社区规范化管理模式的具体内容包括：社区卫生资源的整合与充分合理利用、全科团队的组建与分工、糖尿病管理流程规范化、健康档案管理网格化、实施全面和有效地健康教育,以及合理的考核指标。(2)到研究结束,干预组共管理222名糖尿病患者,对照组共管理232名糖尿病患者。干预组和对照组的人群在性别、年龄、职业、籍贯、文化程度等人口学特征方面,无显著性差异(P>0.05)。(3)干预前(2005年第一季度),干预组标准随访率为97.83%,对照组标准随访率为78.05%,两组随访情况无显著性差异(χ2=0.513,P=0.474)；干预2年后(2006年第四季度),干预组标准随访率96.83%,对照组标准随访率66.67%,两组的随访情况出现了显著性差异(χ2=4.198,P=-0.040)；到研究结束(即2009年第二季度),干预组标准随访率为90.99%；对照组标准随访率44.40%,两组之间存在极明显差异(χ2=22.224,P<0.01)。(4)干预前(2005年第一季度),干预组糖尿病患者血糖控制理想率为19.57%,对照组为12.20%,两组无显著性差异(χ2=0.633,P=0.426)；干预2年后(2007年第二季度),干预组糖尿病患者血糖控制理想率27.27%；对照组为13.67%,两组之间出现显著性差异(χ2=4.566,P=0.033)。干预3.5年后(2008年第三季度),两组之间开始出现极显著性差异(P<0.01)。干预前(2005年第一季度),干预组糖尿病患者血糖控制达标率为50%,对照组为31.71%,两组无显著性差异(χ2=1.255,P=0.263)；干预2年后(2007年第一季度),干预组糖尿病患者血糖控制达标率47.13%；对照组为24.30%,两组之间出现显著性差异(χ2=5.326,P=0.021)。干预3.5年后(2008年第三季度),两组之间开始出现极显著性差异(P<0.01)。(5)干预前(2005年第一季度),干预组的平均空腹血糖值为8.211±3.2743mmol/L,对照组为8.066±1.6673mmol/L,两组血糖值无明显差别(P>0.05)。干预4.5年后(2009年第二季度),干预组的平均空腹血糖值为7.061±1.6873mmol/L,对照组为7.343±1.5118mmol/L,两组血糖值存在显著性差异(P<0.05)。(6)到2009年第二季度截止,干预组共有153人有合并症或并发症,对照组有191人有合并症或并发症,两组之间比较存在显著性差异(P<0.01)。2、糖尿病社区规范化管理模式在浙江省内推广应用效果(1)团队建设该模式对已建立和未建立全科团队的社区均有帮助,回馈的两个社区通过整合重组,将责任医生团队进行科学合理调整,建立了由责任医生、公共卫生联络员、疾控人员、护士和妇幼保健人员组成的新团队。(2)糖尿病管理情况糖尿病社区规范化管理模式在发现糖尿病患者人数与管理人数、居民慢性病知识知晓率、居民对社区卫生服务工作的满意度,以及健康教育开展情况等方面有一定的影响,但在糖尿病患者的管理率与控制率方面尚未出现明显的变化。结论1、糖尿病社区规范化管理模式应包括资源利用、全科团队、工作流程、信息管理、健康教育、考核指标几个方面的内容。2、糖尿病社区规范化管理对保持高的标准随访率、增加血糖控制达标率、降低平均空腹血糖值、减少并发症的发生有效。标准随访率的效果出现在干预2年后,但该阶段效果并不稳定,在干预4年后方趋于稳定；血糖控制达标率在干预1年半以后开始出现明显效果；平均空腹血糖值在干预3年后开始出现明显效果。3、糖尿病社区规范化管理模式推广应用1年后,推广社区在团队建设、发现糖尿病患者的人数和管理的人数、居民慢性病知识知晓率、居民对社区卫生服务工作的满意度方面较前改善,糖尿病的管理率和控制率整体变化不大。更多还原

【Abstract】 BackgroundIn the past 20 years, the morbidity rate of diabetes in China increased rapidly. In 2010, there are more than 92 million diabetic patients in China. China becomes a country with the largest number of diabetic patients in the world. Diabetes has characteristics such as long duration, many complications, and high rate of disability, which will bring great burden to individuals, families and the government. Diabetes becomes an urgent public health problem. Therefore, how to control and manage diabetes effectively is an urgent issue to be resolved.China’s community health service develops rapidly in the last 20 years. Many community health service organizations have begun to manage diabetes, though, the content, style and procedures of diabetes management are different from each other. There is lacking of a uniform standard of diabetes management model for community. Health departments in many regions of China explored the community management of diabetes, and created many different models of diabetes management. Generally speaking, there is lacking of an effective management model, and the present diabetes management in community is far from perfect.Many domestic and international experiences have showed that manage diabetes in community is the most effective approach. Although diabetes management in community in China is still at the initial stage, community health services as the integrated control platform is an inevitable trend. Thus, it is essential to develop the standardized management model of diabetes in community.ObjectiveInvestigate a community in Hangzhou city of Zhejiang province which carries out the standardized management in patients with diabetes, summarize its management model, and analyze its effect in this community and in other community which applied its model. Study in the standardization management of diabetes community, and discuss the model in community. Provide references for the management of chronic diseases in communities in China.Methods1. Literature reviewDomestic and foreign literatures which related to the topic of standardized management of community-related chronic disease research (especially diabetes) were reviewed comprehensively. Studies, experiences, and effects of chronic disease (especially diabetes management) management at home and abroad were investigated. Research status, policies, and the current implementation of diabetes management in community in China were surveyed.2. Sampling approach(1) Purposive samplingA community in Hangzhou, which carries out the standardized management in patients with diabetes, was chosen as the study group. Another similar community, which patients with diabetes were managed without carrying out the standardized, was chosen as the matched group.(2) Cluster samplingThe general information and follow-up information of diabetic patients in two groups in past 5 years were investigated and analyzed.(3) Random sampling Four communties extracted from thirty communities was chosen as the study group. These thirty communities which carried out standardization management of diabetes in 2009-2010, were the base communities of chronic disease management in Zhejiang province.3. InterviewsInvestigate the specific measures and empirical methods in community management of diabetes through interviewing with the staff in the community health services.4. InvestigationPatients’general information and follow-up data before and after application of standardized management models are investigated.Results1. Diabetes standardized management in community(1) Standardized management model of diabetes in community includes: utilization of the community health resources, formation of the general team and the division of labor, diabetes management process standardization, and health records management grid, the implementation of a comprehensive and effective health education Reasonable indicators of several aspects of the assessment(2) In the end, there are 222 persons in study group and 232 persons in control group. No significant difference (P> 0.05) was found between the study group and control group of people in the sex, age, occupation, native place, education and other aspects of demographic characteristics.(3) At baseline (the first quarter of 2005), the follow-up rate was 97.83% in the study group, while that of the control group was 78.05%. There was no significant difference between them (x2=0.513, P=0.474). Two years later (the fourth quarter of 2006), the follow-up rate were 96.83% and 66.67% for the study group and the control group, respectively, exhibiting a significant difference (χ2=4.198, P=0.040); To the end of the study (ie, the second quarter of 2009), the follow-up rate were 90.99% and 44.40% for the study group and the control group, respectively, resulting a very significant difference between the two groups (x=22.224, P<0.01).(4) At baseline (the first quarter of 2005), the rate of ideal blood glucose control (RI) were 19.57% and 12.20% in the study group and the control group, respectively. No significant difference between the two groups was found (χ2=0.633, P=0.426). In the second quarter of 2007, the RI were 27.27% and 13.67% for the study group and the control group, exhibiting a significant difference (χ2=4.566, P=0.033). In the third quarter of 2008, a very significant difference was found between them (P<0.01). In the first quarter of 2005, the compliance rate of blood glucose control (RC) were 50% and 31.71% for the study group and the control group, respectively. No significant difference was found between the two groups (χ2=1.255, P=0.263). In the first quarter of 2007, the Rc were 47.13% and 24.30% for the study group and the control group, exhibiting a significant difference between the two groups (χ2=5.326, P=0.021). In the third quarter of 2008, a very significant difference was found between the two groups (P<0.01).(5) In the first quarter of 2005, the average fasting blood glucose were 8.211±3.2743 mmol/L and 8.066±1.6673 mmol/L for the study group and the control group, respectively. No significant difference was found between the two groups (P> 0.05). In the second quarter of 2009, the average fasting plasma glucose value were 7.061±1.6873 mmol/L and 7.343±1.5118 mmol/L for the study group and the control group respectively, resulting a significantly different between the two groups (P<0.05).(6) To the end of the second quarter of 2009,153 patients were found have complications or complications in the study group, while in the control group there were 191 patients have complications or complications. A very significant difference was found between the two groups (P<0.01). 2. The effect of diabetes standardized management model in the other communties of Zhejiang province(1) The construction of GP’s teamThe model is helpful for the community which has been established the GP’s team or not. Two of them have built a new GP’s team, which is consist of GPs, public health managers, nurses and other Professional Staffs.(2)The effect of diabetes managentmentThe model is good for some aspects in community health service, such as discover and management of diabetes, the awareness of residents on the knowledge of chronic disease, the residents’satisfaction on community health service, and so on. There is no evident change on the manage rate and control rate of diabetes.Conclusions1. A standardized management model of diabetes in community should include following aspects:community resource utilization, general practitioners’team, workflow, information management, patient’s education, and assessment indicators.2. The standardized management of diabetes in the community plays an important role in maintaining the continued follow-up, controlling blood glucose, decreasing the incidence of complication in patients with diabetes. It is an effective way to manage patients with diabetes in community.3. The Standardized model applied one year later, some aspects were improved, such as General Practitioners’team building, the patients’number of discover and manage, the residents’knowledge of chronic disease, and the residents’satisfaction on community health service.更多还原