CAJ | 학술논문

目的：探讨糖尿病患者医院-社区-患者一体化管理的效果。方法：收集本社区自愿接受医院-社区-患者一体化管理的糖尿病患者40例，同时收集同期本社区未接受医院-社区-患者一体化管理的糖尿病患者20例作为对照组进行比较，管理组每周应用血糖仪检查空腹、三餐前、三餐后2 h末梢血糖水平，每月检查空腹血糖和餐后2 h血糖水平，每3个月检查1次糖化血红蛋白(HbA1c)，每半年检查1次并发症发生情况。社区专门人员每周对患者进行1次电话随访，对患者进行患者饮食指导、运动指导和用药指导等。对照组不进行各种指导、随访和检查。结果：经过管理后，管理组生活质量评分、血糖达标率、糖尿病并发症筛查率、糖尿病知识知晓率、合理用药、合理运动、饮食控制、定期自我检测HbA1c、定期自我检测血糖方面明显优于对照组，两组比较有统计学意义(P＜0.05)，管理组经过管理1年后，空腹血糖、餐后2 h血糖和HbA1c均明显下降，与对照组比较差异有统计学意义(P＜0.05)。结论：医院-社区-患者一体化管理可以有效控制糖尿病患者血糖，值得社会推广。
목적：탐토당뇨병환자의원-사구-환자일체화관리적효과。방법：수집본사구자원접수의원-사구-환자일체화관리적당뇨병환자40례，동시수집동기본사구미접수의원-사구-환자일체화관리적당뇨병환자20례작위대조조진행비교，관리조매주응용혈당의검사공복、삼찬전、삼찬후2 h말소혈당수평，매월검사공복혈당화찬후2 h혈당수평，매3개월검사1차당화혈홍단백(HbA1c)，매반년검사1차병발증발생정황。사구전문인원매주대환자진행1차전화수방，대환자진행환자음식지도、운동지도화용약지도등。대조조불진행각충지도、수방화검사。결과：경과관리후，관리조생활질량평분、혈당체표솔、당뇨병병발증사사솔、당뇨병지식지효솔、합리용약、합리운동、음식공제、정기자아검측HbA1c、정기자아검측혈당방면명현우우대조조，량조비교유통계학의의(P＜0.05)，관리조경과관리1년후，공복혈당、찬후2 h혈당화HbA1c균명현하강，여대조조비교차이유통계학의의(P＜0.05)。결론：의원-사구-환자일체화관리가이유효공제당뇨병환자혈당，치득사회추엄。
Objective:To discuss the effect of the diabetic patients' Hospital-Community-Patients integration management. Method:40 patients with diabetic accept the Hospital-Community-Patients integration management as the management group, over the same period,20 patients with diabetic did not accept the Hospital-Community-Patients integration management as the control group.Compare the two groups.The management group used blood glucose meter to check fasting、before meals、after meals 2 h peripheral blood glucose levels every week,to check fasting blood glucose and 2 h postprandial blood glucose levels every month,to check glycosylated hemoglobin(HbA1c)every three months,the complications were checked once every six months. Community specialists weekly follow-up the patients by telephone,and told them dietary guidance,exercise and medication guidance.The control group without any guidance,follow up and check.Results:After management,the management group in quality of life scores,standard rate,glucose screening for diabetic complication rate,the awareness rate of diabetes mellitus、rational drug use,reasonable exercise,diet,regular self detection of HbA1c,regular self monitoring of blood glucose were significantly better than those of the control group,and the differences of two groups were statistically significant(P<0.05).The management group after administration for 1 year,fasting blood glucose,2 h postprandial blood glucose and HbA1c were significantly decreased,and there was statistical significance compared with the control group(P<0.05).Conclusion:Hospital-Community-Patients integration management can effectively control blood glucose in diabetic patients.It is worthy of social promotion.