赵晓燕+祝丽芳+周建根+李元召

摘 要 目的：探讨全-专联合模式下家庭医生对2型糖尿病优化管理的实践与效果评估。方法：在马陆镇实施全-专联合模式对社区2型糖尿病患者进行优化管理，评估全-专联合优化管理模式对入组患者管理前后的临床指标效果、区域医疗协作情况、家庭医生服务能力和患者满意度变化的情况。结果：在全-专联合模式下管理12个月后，患者临床管理效果提升显著，区域医疗协作机制建立，家庭医生服务能力明显提升，患者满意度明显提升。结论：全-专联合模式对社区2型糖尿病优化管理提升了慢性病管理质量，梳理明确了社区与三级医院之间的分级诊疗内容与秩序，推动了社区家庭医生制服务的发展，提升了社区卫生服务的内涵。

关键词 糖尿病 家庭医生 管理

中图分类号：R587.1 文献标识码：A 文章编号：1006-1533（2016）08-0038-03

Practice and evaluation of the optimal management of type 2 diabetes by the family doctors under the family doctor-specialist federation pattern in the rural community

ZHAO Xiaoyan， ZHU Lifang， ZHOU Jiangen， LI Yuanzhao

（ Malu Community Health Service Center of Jiading District， Shanghai 201801， China）

ABSTRACT Objective： To discuss the practice and effective evaluation of the optimal management of type 2 diabetes by the family doctors under the family doctor-specialist federation pattern in the rural community. Methods： The family doctorspecialist federation pattern was carried out for the optimal management of type 2 diabetes in Malu Town， and under the family doctor-specialist federation pattern， the changes of the clinical indicators of the enrolled patients before and after the management， regional medical cooperation， family doctor service ability and the patients satisfaction were evaluated. Results： After one year of the management of the family doctor-specialist federation pattern， clinical management effect of patients was significantly improved， the regional medical cooperation mechanism was established， the family doctor service capacity was obviously improved， and the patients satisfaction was significantly improved. Conclusion： The family doctor-specialist federation pattern for the optimal management of type 2 diabetes improves the quality of chronic disease management clearly， defines the contents and orders of the tiered medical service between the community and tertiary hospital， promotes the development of the community family doctor system service， and enhances the connotation of community health services.

KEY WORDS diabetes； family doctors； management

2007年嘉定区积极响应新医改要求，成立家庭医生制服务试点。2012年起，随着上海各区县全面推开家庭医生责任制服务，马陆镇社区卫生服务中心的全科医生转为家庭医生，糖尿病患者根据辖区分布和签约情况交由家庭医生管理[1]。然而，家庭医生的能力水平尚不能满足糖尿病的健康管理，缺乏高质量的随访和基本治疗[2]。2013年辖区在册管理糖尿病患者3 868例，糖尿病理想血糖控制率（年内2/3的时间空腹血糖≤7.0 mmol/L）仅为53.5%。2008年以来，全国各地积极探索区域卫生资源纵向整合的新模式[3-4]，但由于各级医院功能定位、临床职业者专业能力、患者就医习惯、医保支付方式等问题，以双向转诊为重要内容的卫生资源整合尚未取得明显实效[5]。……