杨眉 郏文杰

[摘要] 目的 评估家庭团队与专科联合对血糖控制不达标患者管理的效果。方法 从马陆镇2017年在册管理的41～81岁糖尿病患者中筛选出426例糖化血红蛋白>7%，且≤9%患者，分为对照组214例，和研究组212例，对照组患者采用传统管理模式，研究组患者按照辖区区域和签约情况由10名家庭医生管理，管理模式在对照组基础上采用家庭医生与专科医生联合管理，然后统计分析两组患者的血压、血糖、血脂、体重指數。结果 研究组患者管理后较管理前的收缩压、舒张压降低幅度与对照组相比差异无统计学意义（P>0.05）。研究组患者管理后较管理前的空腹血糖、餐后2 h血糖、糖化血红蛋白、低密度脂蛋白、体重指数降低幅度均显著高于对照组，差异有统计学意义（P<0.05）。结论 家庭团队与专科联合对血糖控制不达标患者管理的效果较常规社区医生组模式好。

[关键词] 家庭团队与专科联合;血糖控制不达标;管理

[Abstract] Objective To evaluate the effect of the joint management of family teams and specialists on patients with suboptimal glycemic control. Methods From 426 diabetic patients aged 41 to 81 years under management in Malu Town in 2017， 426 patients with glycated hemoglobin> 7% and ≤ 9% were selected and divided into the control group 214 and the study group 212 patients. Patients in the control group adopted traditional management model. Patients in the study group are managed by 10 family doctors according to the jurisdiction area and the contract. The management mode is based on the management of the family doctors and specialists， and then the blood pressure， blood glucose， lipids， and weight index of the two groups of patients were statistically analyzed. Results The reduction of systolic blood pressure and diastolic blood pressure in the study group after management compared with that before management was not statistically significant different compared with the control group （P>0.05）. Compared with the control group， the fasting blood glucose， 2h postprandial blood glucose， glycated hemoglobin， low-density lipoprotein， and body mass index of patients in the study group were significantly higher than those in the control group，and the difference was statistically significant（P<0.05）. Conclusion The combined effect of family team and specialist on the management of patients with substandard blood glucose control is better than that of the conventional community doctor group.

[Key words] Family team and specialist combination; Substandard blood glucose control; Management

在我国，近年来，糖尿病患病率在日益加剧的城市化、人口老龄化、不断改变的生活方式的作用下日益提升[1]。近年来，糖尿病流行病学调查结果表明[2]，在我国，糖尿病患病率达到了11.6%。但是，临床却具有较低的血糖控制达标率。相关医学文献统计结果表明[3]，在我国，成年人糖尿病患者只有25.8%的治疗率，其中接近或达到血糖控制目标的患者仅占39.7%。因此，临床应该积极采取有效措施对糖尿病患者有效控制与管理。该研究评估了家庭团队与专科联合对血糖控制不达标患者管理的效果，现报道如下。

1  资料与方法

1.1  一般资料

从马陆镇2017年在册管理的40～75岁糖尿病患者中筛选出426例糖化血红蛋白>7%，且≤9%患者，分为对照组214例，和研究组212例。研究组患者……