CAJ | 학술논문

2年来上海市石门二路社区卫生服务中心结合<上海市社区糖尿病防治工作指南(试行,2005)>对578名糖尿病及糖调节异常患者进行分组管理.其中70%为社区站点全科医生发现传报,60%由全科医生进行随访管理,40%由防保医生随访管理.结果提示传统的疾病管理模式是针对急性病的医疗管理模式,不能满足慢性病卫生保健的需求.以社区卫生服务中心为主体,全科医生为骨干进行慢病管理是较为理想的模式,这种模式防治结合,对减轻慢性病所造成的巨大危害及经济负担,缓解越来越紧张的医患关系均具有重要作用.
2년래상해시석문이로사구위생복무중심결합<상해시사구당뇨병방치공작지남(시행,2005)>대578명당뇨병급당조절이상환자진행분조관리.기중70%위사구참점전과의생발현전보,60%유전과의생진행수방관리,40%유방보의생수방관리.결과 제시전통적질병관리모식시침대급성병적의료관리모식,불능만족만성병위생보건적수구.이사구위생복무중심위주체,전과의생위골간진행만병관리시교위이상적모식,저충모식방치결합,대감경만성병소조성적거대위해급경제부담,완해월래월긴장적의환관계균구유중요작용.
Based on Shanghai Guideline for Diabetes Prevention and Treatment(2005), 578patients with diabetes or abnormal glucose metabolism in Shi Men Er Road Community were managed at different levels during the past 2 years. Seventy percent of the patients were identified by general practitioners. Follow-up was initiated by general practitioners(60%)or other healthcare providers(40%).Our findings suggested that traditional disease management model focused mainly on acute conditions, while community health center-based model Was expected to meet the need for chronic disease prevention and treatment and play an important role in minimizing economic burden and improving doctor-and-patient relationship.