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目的了解社区糖尿病家庭支持与管理现状,探索基于家庭医生服务的糖尿病“自我-家庭-社区”管理模式。方法在中心家庭医生管理的3607例糖尿病患者中随机抽取150户进行问卷调查,分析社区家庭与糖尿病管理现状、家庭支持与血糖控制的关系等。结果血糖控制好坏与患者病程有关(P<0.05);血糖控制理想组合并慢性病明显少于血糖控制不良组(P<0.05)。血糖控制理想组在认知、饮食、治疗、监测、心理等5个方面均优于血糖控制不良组(P<0.05)。家庭支持良好组的患者除药物治疗外,在糖尿病认知、饮食控制、规律运动、指标监测、遵医依从性方面都明显优于家庭支持一般组(P<0.05)。家庭支持良好组患者血糖控制、低血糖发生次数、血压控制等方面优于家庭支持一般组(P<0.05)。糖化血红蛋白的监测(3~6个月1次)仅为46例,占30.7%,尿微量蛋白监测(1次/6个月)37例,占24.7%,眼底检查10例(发病以来),占6.7%。结论家庭支持对社区糖尿病综合管理有着积极意义,但目前的社区糖尿病管理与家庭支持现况不容乐观,有待引导与宣传。
Objective To understand the status quo of community diabetes family support and management and to explore the diabetes “self - family - community ” management model based on the family doctor service. Methods A total of 1507 diabetic patients were randomly selected from 3607 diabetes patients managed by family doctors to conduct a questionnaire survey to analyze the current status of community family and diabetes management and the relationship between family support and blood glucose control. Results Good or bad blood glucose control was related to the duration of the disease (P <0.05). The ideal combination of glycemic control and chronic disease was significantly less than the poor glycemic control group (P <0.05). The glycemic control ideal group was better than the poor glycemic control group in cognitive, diet, therapeutic, monitoring, psychological and other aspects (P <0.05). In addition to drug treatment, patients with good family support group were significantly better than the general family support group (P <0.05) in the aspects of diabetes cognition, diet control, regular exercise, index monitoring and compliance compliance. Family support for patients with good glycemic control, the frequency of hypoglycemia, blood pressure control and other aspects than the general family support group (P <0.05). HbA1c was detected only in 46 cases (30.7%) in 3 to 6 months, 37 (24.7%) in urine microalbuminuria monitoring (1/6 months) and 10 in fundus examination Accounting for 6.7%. Conclusion Family support has positive significance for the integrated management of community diabetes. However, the current status of community diabetes management and family support is not optimistic and needs further guidance and publicity.