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目的探讨全科医生-专家团队在社区糖尿病管理中的优势。方法选取社区216例2型糖尿病患者,随机分为观察组和对照组,每组各108例。对照组患者的健康管理由社区全科医生负责,指导其进行合理运动和膳食,每年对其进行健康教育。观察组患者的健康管理由全科医生-专家团队共同负责。除全科医生外,内分泌专家团队直接参与患者的健康管理(药物治疗与行为干预并重)。对患者进行定期和主动随访,患者可在医院与社区间双向转诊。患者一旦出现异常则立刻转至医院进行进一步治疗。两组患者管理期均为3年。对比两组管理前后生化指标。结果两组在进行健康管理前各项生化指标的差异无统计学意义(P>0.05)。观察组患者管理后与对照组以及管理前相比,差异有统计学意义(P<0.05)。对照组管理前后的差异无统计学意义(P>0.05)。结论全科医生-专家团队管理模式有利于对社区和医院资源进行整合,使社区全科医生的健康管理能力进一步提高,有利于糖尿病患者各项生化指标的改善。
Objective To explore the advantages of general practitioners and expert teams in community diabetes management. Methods A total of 216 patients with type 2 diabetes in the community were enrolled and randomly divided into observation group and control group with 108 cases in each group. The health management of patients in the control group is the responsibility of the community GP, which guides them to exercise and diet regularly and carries out health education annually. The health management of patients in the observation group is the responsibility of the general practitioner-expert team. In addition to general practitioners, the endocrinologist team is directly involved in the patient’s health management (both medications and behavioral interventions). Regular and active follow-up of patients, patients can be two-way referral between the hospital and community. Patients in the event of anomalies, immediately transferred to the hospital for further treatment. Management of both groups were 3 years. Before and after the two groups compared biochemical indicators. Results There was no significant difference in biochemical indexes between the two groups before the health management (P> 0.05). The difference between the observation group and the control group and before management was statistically significant (P <0.05). The control group before and after the difference was not statistically significant (P> 0.05). Conclusion The GP-expert team management model is conducive to the integration of community and hospital resources, and further improves the health management ability of general practitioners in the community, which is beneficial to the improvement of various biochemical indexes in patients with diabetes.