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目的探讨糖尿病社区-医院一体化管理模式。方法对中华、厦港两个社区医疗中心所管辖的701例糖尿病患者实施社区、医院一体化管理,通过社区-医院的双向转诊,让患者得到“无缝化”的医疗服务。比较管理前后糖尿病患者的血糖、生活方式变化情况。结果 701例糖尿病患者建档时空腹血糖平均为(7.6±2.3)mmol/L,餐后2h血糖平均为(9.9±2.5)mmol/L,管理2年后空腹血糖降至(6.9±1.7)mmol/L,餐后2h血糖降至(9.0±2.0)mmol/L,随着管理时间的延长,空腹血糖、餐后2h血糖均呈下降趋势(P<0.05);糖尿病患者的生活方式(限盐、运动、饮酒控制、体质量控制)有明显改善,与管理前比较,差异均有统计学意义(P<0.01)。结论社区、医院一体化糖尿病规范化治疗和管理服务模式中双向转诊是重要内容和关键环节,是提供无缝式管理和连续性服务的重要手段,“院办院管”能有效消除医院与社区间双向转诊、技术支持和信息共享等一体化协作的阻碍。
Objective To explore the community-based management model of diabetes. Methods A total of 701 diabetes patients under the jurisdiction of the two community health centers in China and Xiamen were integrated into community and hospitals. Through community-hospital two-way referrals, patients were given “seamless” medical services. Compare the changes of blood glucose and lifestyle before and after the management of diabetes. Results The average fasting blood glucose (FBG) of 701 diabetic patients was (7.6 ± 2.3) mmol / L at baseline and (9.9 ± 2.5) mmol / L at 2 hours postprandially. The fasting blood glucose dropped to (6.9 ± 1.7) mmol / L, blood glucose dropped to (9.0 ± 2.0) mmol / L at 2h postprandial. With the extension of management time, fasting blood glucose and postprandial 2h blood glucose showed a decreasing trend (P <0.05); diabetic lifestyle , Exercise, alcohol consumption control, body weight control) were significantly improved, compared with before management, the differences were statistically significant (P <0.01). Conclusions Bidirectional referral in the standardized treatment and management service mode of integrative diabetes in hospitals and hospitals is an important content and key link, and it is an important means to provide seamless management and continuity service. Hospital management can effectively eliminate hospitals Obstacles to an integrated collaboration such as community referrals, technical support and information sharing.