论文部分内容阅读
目的:分析联盟内慢性疾病管理平台对高血压糖尿病患者管理效果。方法:选取2018年9月至2019年5月中山市人民医院的高血压、糖尿病患者各200例作为对照组（联盟内慢性疾病管理台实施前），2019年6月至2020年2月中山市人民医院的高血压、糖尿病患者各200例作为观察组（联盟内慢性疾病管理平台实施后）。观察组年龄20～68（57.76±4.71）岁，其中男228例，女172例；对照组年龄20～67（57.34±4.81）岁，其中男216例，女184例。住院期间两组患者给予相同的治疗方案，出院后对照组由临床医师进行定期随访和电话随访，观察组则通过联盟内慢性疾病管理平台对患者出院后行为进行监督和管理。比较两组糖尿病患者出院前（T0）及出院后3个月（T1）、6个月（T2）、9个月（T3）时三酰甘油（TG）、低密度脂蛋白（LDL-C）、糖化血红蛋白（HbAlc）和总胆固醇（TC）水平，比较两组高血压患者出院前（T0）及出院后3个月（T1）、6个月（T2）、9个月（T3）时舒张压（DBP）和收缩压（SBP）水平，并比较两组患者出院后9个月的生活质量评分。结果:两组糖尿病患者T0时TG、LDL-C、HbAlc、TC水平比较，均n P＞0.05；T1、T2、T3时观察组TG、LDL-C、HbAlc、TC水平均明显低于对照组（均n P＜0.05）。两组高血压患者T0时SBP、DBP比较，均n P＞0.05；T1、T2、T3时观察组SBP、DBP水平明显低于对照组（均n P＜0.05）。对照组躯体功能、心理功能、社会关系、物质功能评分分别为（79.33±4.07）分、（81.38±5.89）分、（80.29±5.63）分、（82.69±6.38）分，观察组分别为（87.56±4.12）分、（88.12±5.03）分、（83.45±5.41）分、（86.47±7.10）分，两组比较，差异均有统计学意义（均n P＜0.05）。n 结论:联盟内慢性疾病管理平台对高血压糖尿病患者出院后进行管理，可有效控制患者血糖和血压水平，改善患者生活质量。“,”Objective:To analyze the management effect of the alliance\'s chronic disease management platform on patients with hypertension and diabetes.Methods:Two hundred patients with hypertension and 200 patients with diabetes in the community from September 2018 to May 2019 were selected as a control group (before the implementation of the chronic disease management platform in the alliance), and 200 patients with hypertension and 200 patients with diabetes in the community from June 2019 to February 2020 as an observation group (after the implementation of the chronic disease management platform in the alliance). The observation group were 20-68 (57.76±4.71) years old, and had 228 males and 172 females. The control group were 20-67 (57.34±4.81) years old, and had 216 males and 184 females. During the hospitalization period, both groups were given the same treatment plan. After discharge, the control group was followed up by clinicians on a regular basis and by telephone, while the observation group supervised and managed the patients\' behaviors after discharge through the alliance\'s chronic disease management platform. The levels of triglycerides (TG), low-density lipoprotein (LDL-C), glycosylated hemoglobin (HbAlc), and total cholesterol (TC) before (T0) and 3 (T1), 6 (T2), and 9 months (T3) after discharge were compared between the diabetic patients of these two groups. The diastolic blood pressures (DBP) and systolic blood pressures (SBP) at T0, T1, T2, and T3 were compared between the hypertensive patients of the two groups. The scores of life quality were compared between the two groups at T3.Results:There were no statistical differences in the levels of TG, LDL-C, HbAlc, and TC between the diabetic patients of the two groups at T0 (all n P＞0.05). At T1, T2, and T3, the levels of TG, LDL-C, HbAlc, and TC in the observation group were significantly lower than those in the control group (all n P＜0.05). There were statistical differences in the SBP and DBP between the hypertensive patients of the two groups at T0 (both n P＞0.05). At T1, T2, and T3, the SBP and DBP in the observation group were significantly lower than those in the control group (all n P＜0.05). The scores of physical function, psychological function, social relationship, and material function were (79.33±4.07), (81.38±5.89), (80.29±5.63), and (82.69±6.38) in the control group, and were (87.56±4.12), (88.12±5.03), (83.45±5.41), and (86.47±7.10) in the observation group, with statistical differences (all n P＜0.05).n Conclusion:The chronic disease management platform in the alliance manages patients with hypertension and diabetes after they are discharged from the hospital, which can effectively control their blood glucose and blood pressure and improve their quality of life.