diabetes mellitus medical alliance specialist clinic standardized management
目的：探讨医联体三级医院联合社区开展糖尿病规范化管理的效果。方法：2018年10月起在社区卫生服务中心开设医联体社区糖尿病专科门诊，从社区居民健康档案登记的1290例糖尿病患者中选取愿意接受管理的患者885例，以医联体三级医院专家和社区全科医生相联合的方式提供规范化管理，收集糖尿病并发症知晓率、生活方式、空腹血糖（FPG）、收缩压、舒张压等资料。到2019年12月，规范化管理满1年且资料齐全的患者共计472例。对调查对象自身干预前后两次数据进行比较分析。结果：干预后患者对糖尿病并发症知晓率由44.5%提升为82.2%，生活方式包括调整饮食、参与运动、情绪稳定均有改善，分别从28.0%提升为76.3%、55.6%提升为78.4%、30.5%提升为51.9%，差异有统计学意义（P＜0.001）。患者对糖尿病危险因素控制均有提升，除监测血脂差异无统计学意义外，吸烟、饮酒、控制体重、监测血压前后差异均有统计学意义（P＜0.001）。干预后患者空腹血糖、收缩压、舒张压指标均有改善，差异有统计学意义（P＜0.001）。规范化管理率由25.4%提升为53.3%，血糖控制率从22.3%提升为40.6%，血压控制率由44.5%提升为68.6%，差异有统计学意义（P＜0.001）。结论：医联体三级医院联合社区开展糖尿病规范化管理，有利于提升基层医疗机构糖尿病规范化管理效果与能力，引导社区糖尿病患者到基层医疗机构就诊，促进分级诊疗落实，提高面对面随访真实性。
Objective：To explore the effect of standardized management of diabetes mellitus in the tertiary hospitals of Medical Association combined with community. Method：Since October 2018，the community diabetes specialist clinic of medical alliance has been set up in the community health service center. 885 patients who are willing to accept management are selected from 1290 diabetic patients registered in the community health records. Standardized management is provided by the joint way of experts from the tertiary hospital of the medical alliance and community general practitioners，and the awareness rate of diabetes complications，lifestyle，fasting plasma glucose(FPG)，systolic blood pressure，diastolic blood pressure，etc. are collected. By December 2019，there were a total of 472 patients with complete data and standardized management for one year. The data before and after the intervention were compared and analyzed. Results：After the intervention，the awareness rate of diabetic complications was increased from 44.5% to 82.2%. Lifestyle including diet adjustment，exercise participation and emotional stability were improved from 28.0% to 76.3%，55.6% to 78.4%，and 30.5% to 51.9%，respectively. The difference was statistically significant（χ2 was 144.556，220.667，49.762，44.604，P < 0.001）. Except monitoring blood lipid，there were significant differences in smoking，drinking，weight control and blood pressure monitoring（χ2=29.834，31.543，45.322，85.243，P < 0.001）. After intervention，fasting blood glucose，systolic blood pressure and diastolic blood pressure were improved，the difference was statistically significant（P < 0.001）. The standardized management rate was increased from 25.4%（217/856）to 53.3%（472/885），the blood glucose control rate was increased from 22.3%（191/856）to 40.6%（359/885），and the blood pressure control rate was increased from 44.5%（381/856）to 68.6%（607/885），and the difference was statistically significant（χ2=142.484，67.074，102.781，P < 0.001）. The compliance of blood glucose and blood pressure of patients with standardized management were significantly higher than those without standardized management（P < 0.001）. Conclusion：Thetertiary hospitals of the medical alliance combined with the community to carry out the standardized management of diabetes can improve the effect and ability of the standardized management of diabetes in primary medical institutions，guide the community diabetic patients to the primary medical institutions，promote the implementation of hierarchical diagnosis and treatment，and improve the authenticity of face-to-face follow-up.