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目的评价2型糖尿病(T2DM)患者社区家庭医生团队服务的管理效果。方法选取宁波市鄞州区明楼街道社区卫生服务中心健康管理的T2DM患者267例,实施以门诊医生团队定期随访为重点的社区家庭医生团队服务,记录患者的生活方式、血压、血糖等指标,比较服务前后上述指标的变化情况以评价服务效果。结果随访8个月后,T2DM患者每周运动7 d人数增加14.98%,主动测量体重人数增加5.99%,主动测量血糖人数增加5.61%,每周运动天数、体重测量和血糖监测频率升高(均P<0.05);用药调整率从73.26%降至42.80%(P<0.05);血压正常率从92.40%上升至97.80%(P<0.05),空腹血糖、糖化血红蛋白值变化不明显(均P>0.05)。结论社区家庭医生团队服务对T2DM患者生活方式、用药调整、血压控制的改善有一定效果。
Objective To evaluate the management of community family doctor team services in patients with type 2 diabetes mellitus (T2DM). Methods A total of 267 T2DM patients were selected from community health service center of Minglou Street Community Health Service Center in Yinzhou District of Ningbo City. Community-based family doctor team focused on regular follow-up by outpatient doctors was employed to record the lifestyle, blood pressure and blood glucose of the patients. Service changes before and after the above indicators to assess service effectiveness. Results After 8 months of follow-up, T2DM patients increased 14.98% in exercise 7 days, 5.99% in active weight measurement, 5.61% in active measurement of blood glucose, days of exercise, weight measurement and frequency of blood glucose monitoring (P <0.05); The adjustment rate of medication dropped from 73.26% to 42.80% (P <0.05); The normal rate of blood pressure increased from 92.40% to 97.80% (P0.05), but the changes of fasting blood glucose and glycosylated hemoglobin were insignificant 0.05). Conclusion community family doctor team service on T2DM patients lifestyle, medication adjustment, blood pressure control have some effect.