金玲怡

摘 要 目的：探究“個性化-团队合作”模式在社区老年糖尿病前期患者管理中应用的效果。方法：选取2017年经上海南桥镇社区卫生服务中心糖尿病高危人群筛查中所发现的糖尿病前期人群293人中符合纳入标准的180人，随机分为对照组（90人）和干预组（90人），对照组有男性42例，女性48例，平均年龄（64.53±4.78）岁；研究组有男性41例，女性49例，平均年龄（65.12±4.26）岁。对对照组患者实施定期健康宣教管理，对干预组患者按照“个性化-团队合作”模式进行糖尿病前期患者管理。比较两组患者干预前后的糖尿病知识知晓率、运动达标率、血糖改善率。结果：干预后两组患者糖尿病知识知晓率、运动达标率、血糖改善率均比干预前有明显提高（P<0.001），但干预后干预组的糖尿病知识知晓率、运动达标率、血糖改善率达标率均显著高于对照组（P<0.05）。结论：“个性化-团队合作”模式在社区老年糖尿病前期患者管理中有较好的效果。

关键词 糖尿病前期；老年人；个性化-团队合作模式；应用

中图分类号：R587.1 文献标志码：A 文章编号：1006-1533（2020）10-0048-03

Application of personalization team cooperation mode in the community management of elderly patients with pre-diabetes

JIN Lingyi

（General Medical Office of Nanqiao Community Health Service Center of Fengxian District， Shanghai 201499， China）

ABSTRACT Objective： To explore the application effect of the “personalization team cooperation” mode in the community management of elderly patients with pre-diabetes. Methods： One hundred and eighty patients who met the inclusion criteria were selected among the 293 pre-diabetic populations found in the screening of high-risk diabetes group in Nanqiao Community Health Service Center of Shanghai in 2017， and divided into a control group with 90 cases and an intervention group with 90 cases. The control group consisted of 42 males and 48 females， with an average age of （64.53±4.78） years； and the intervention group consisted of 41 males and 49 females， with an average age of （64.12±4.26） years. The control group implemented regular health education and management， and the intervention group were managed according to the “personalization team cooperation” mode. The diabetes knowledge awareness rate， exercise compliance rate and blood glucose improvement rate of the patients were compared between the two groups before and after the intervention. Results： The awareness rate of diabetes， exercise compliance rate and blood glucose improvement rate in the two groups were significantly higher than those before the intervention（P<0.001）， but the awareness rate of diabetes knowledge， exercise compliance rate and blood glucose improvement rate in the intervention group were significantly higher than those in the control group after the intervention（P<0.05）. Conclusion： The “individualization team cooperation” mode has a good effect in the community management of the elderly patients with pre-diabetes.

KEY WORDS pre-diabetes； elderly people； personalized team cooperation mode； application

据不完全统计，我国是糖尿病患者最多的国家之一[1]，糖尿病严重威胁着人们的身体健康。在美国糖尿病协会和世界卫生组织（WHO）诊断标准中，将糖耐量受损（IGT）与空腹血糖受损（IFG）合称为“糖调节受损”（IGR），是人体处于糖代谢紊乱的前期阶段，该阶段为可逆阶段，应在早期采取适当的干预，以达到减缓转为糖尿病的目的，从而降低糖尿病发生率。因此，对于糖尿病前期人群的健康管理显得格外重要。社区健康干预是重要管理部分，通过健康教育和科学的干预，提高人们对糖尿病的认知率，减少死亡率和残疾率，减少治疗成本[2]。本研究旨在评价“个性化-团队合作”模式在社区老年糖尿病前期患者管理中的应用效果。……