CAJ | 학술논문

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。
목적：대혈당공제불체표환자실시다원화관리，위심화사구당뇨병관리제공의거。방법통과계통사선학정인군진행첨약관리，이예약문진、주제활동、가정지도급정기감측등수단개변환자불량생활습관화규정치료오구。결과100례혈당공제불체표환자불량생활방식화생물학지표교관리전유현저제고（불량생활방식비례유81%하강지59%；공복혈당체표솔유2%상승도36%，당화혈홍단백체표솔유9%상승도35%）。결론대중점당뇨병환자진행다원화관리가이취득비교명현적효과，시사구당뇨병관리중불가결소적방법지일。
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.