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[目的]探讨跟踪管理服务对100例糖尿病患者的效果及分析。[方法]2008～2009期间,随机抽取的某院糖尿病病区100例住院患者,待患者出院后,对其进行跟踪管理服务。每月回访1次,每次大约20～30 min。[结果]与跟踪管理前的FBG、PBG和HbA1c相比,跟踪管理后3个月的FBG、PBG和HbA1c有所降低;跟踪管理后6个月的FBG、PBG和HbA1c明显降低,P﹤0.05,差异有统计学意义;跟踪管理后12个月的FBG、PBG和HbA1c显著性降低,P﹤0.01,差异有统计学意义。与跟踪管理前的收缩压(136.9±16.3)mmHg和舒张压(81.3±8.8)mmHg相比,跟踪管理后3个月有所下降,但跟踪管理后6和12个月的收缩压和舒张压明显降低,P﹤0.05,差异有统计学意义。与跟踪管理前对药物治疗的依从性好、自觉进行食疗和主动参与运动相比,跟踪管理后3个月有所提高,跟踪管理后6和12个月明显提高,P﹤0.05,差异有统计学意义。与跟踪管理前的发生低血糖、漏诊相比,跟踪管理后3个月、后6个月和后12个月都明显降低,P﹤0.05,差异有统计学意义。[结论]通过跟踪管理服务,患者的病情得到了满意的控制,患者自我管理能力得到了明显的改善,值得临床广泛推广。
[Objective] To investigate the effect and analysis of follow-up management services on 100 diabetic patients. [Method] Between 2008 and 2009, 100 inpatients with diabetes mellitus in a hospital were randomly selected. After the patients were discharged from hospital, they were followed up for management. 1 visit a month, each about 20 ~ 30 min. [Results] FBG, PBG and HbA1c were decreased 3 months after follow-up management compared with those before follow-up management, FBG, PBG and HbA1c were significantly decreased 6 months after follow-up management, P <0.05 , The difference was statistically significant; FBG, PBG and HbA1c significantly decreased 12 months after follow-up management, P <0.01, the difference was statistically significant. Compared with systolic blood pressure (136.9 ± 16.3) mmHg and diastolic blood pressure (81.3 ± 8.8) mmHg before follow-up management, there was a decrease after 3 months of follow-up management but systolic and diastolic blood pressure at 6 and 12 months after follow-up management Significantly lower, P <0.05, the difference was statistically significant. Compared with the follow-up management of drug treatment compliance, and consciously carry out diet and active participation in sports compared to 3 months after the tracking management has improved, 6 and 12 months after tracking management significantly improved, P <0.05, the difference was statistically Significance of learning. Compared with the incidence of hypoglycemia and missed diagnosis before follow-up management, the three months, six months and 12 months after follow-up management were significantly decreased, P <0.05, the difference was statistically significant. [Conclusion] Through the follow-up management service, the patient’s condition has been satisfactorily controlled, and the patient self-management ability has been significantly improved, which deserves wide clinical promotion.