CAJ | 학술논문

目的：探讨糖尿病社区管理优化路径。方法从体检服务、巡诊服务和健教服务三个方面提出糖尿病社区管理优化路径，通过观察A社区及B社区，比较两者的年就诊人次、血糖及血脂水平、糖尿病知识知晓率、生活方式及治疗依从性改善情况。结果①观察组社区卫生服务机构年就诊人次较对照组明显增加，但二级及以上医疗机构年就诊人次及高危病人年就诊人次数较对照组减少。②观察组空腹血糖、甘油三酯水平均明显低于对照组(P<0.05)。③在糖尿病知识知晓率方面，关于血糖达标值、糖尿病饮食及慢性并发症、血糖监测，观察组均优于对照组(P<0.05)；关于生活方式及治疗依从性的改善上，在血糖监测、控制饮食及按医嘱服药上观察组均明显好于对照组(P<0.05)。结论通过糖尿病社区管理优化路径，提高了糖尿病患者对疾病的认知水平，形成积极的态度和健康的行为，最终有利于疾病的控制。
목적：탐토당뇨병사구관리우화로경。방법종체검복무、순진복무화건교복무삼개방면제출당뇨병사구관리우화로경，통과관찰A사구급B사구，비교량자적년취진인차、혈당급혈지수평、당뇨병지식지효솔、생활방식급치료의종성개선정황。결과①관찰조사구위생복무궤구년취진인차교대조조명현증가，단이급급이상의료궤구년취진인차급고위병인년취진인차수교대조조감소。②관찰조공복혈당、감유삼지수평균명현저우대조조(P<0.05)。③재당뇨병지식지효솔방면，관우혈당체표치、당뇨병음식급만성병발증、혈당감측，관찰조균우우대조조(P<0.05)；관우생활방식급치료의종성적개선상，재혈당감측、공제음식급안의촉복약상관찰조균명현호우대조조(P<0.05)。결론통과당뇨병사구관리우화로경，제고료당뇨병환자대질병적인지수평，형성적겁적태도화건강적행위，최종유리우질병적공제。
Objective To investigate optimum pathway of community based management for diabetes. Methods The optimum pathway was based on service of health examination, clinical follow-up, and health education. Between A and B community based management,we compared the difference in frequency of doctors' office visiting in one year, fasting blood glucose and blood fat, the diabetes knowledge, improvement of life style and patient's willingness. Results ①The frequency of doctors' office visiting in one year in observation group were significantly higher than that of the control group, but were lower than control group in over Second-class Hospital and high-risk patients. ②The fasting blood glucose and blood fat in observation group were significantly lower than that of the control group(P<0.05). ③The awareness rate about the blood glucose level, diabetes diet,chronic complications and blood sugar monitoring in in ob-servation group were significantly higher than control group(P<0.05);In improvement of life style and patient's willing-ness,the observation group was better than control group of blood checks,diet control and medication(P<0.05). Conclu-sion Because of the optimum pathway of community based management for diabetes,the diabetes patient has more knowledge in diabetes , positive attitude and healthy behavior,so at last, it is good for treatment.