2019 年第 3 期 第 14 卷

北京市2型糖尿病患者社区综合管理现况调查

Cross-sectional investigation of type 2 diabetes management in a community center in Beijing

作者：彭文龙马立萍周玉杰张永辉马越王德广

英文作者：

单位：100029首都医科大学附属北京安贞医院心内十二病房（彭文龙、周玉杰、马越、王德广），全科医疗科（马立萍）；100029北京市大屯社区卫生服务中心全科医学科（张永辉）

英文单位：

关键词：糖尿病，2型；社区管理；现况调查

英文关键词：

• 摘要：

• 【摘要】目的    分析北京市2型糖尿病患者社区综合管理现状，了解所调查社区在糖尿病管理方面存在的优势与不足，提出有针对性的整改措施。方法    选取2017年1月1日至12月31日确诊为2型糖尿病并连续就诊于北京市大屯社区卫生服务中心的患者604例为研究对象进行横断面研究，通过就诊系统及慢性病管理系统收集患者就诊一般信息，通过电话随访患者过去1年内血糖自我监测、低血糖次数、运动治疗、饮食治疗、服药依从性、糖尿病健康教育等情况。结果    604例患者中建立糖尿病慢性病档案者153例，建档率为25.3%；最终电话随访299例（49.5%），其中死亡2例。随访患者中，每年进行≥1次血生化检验者占89.3%（267/299），每年进行≥2次糖化血红蛋白(HbA1c)检验者占50.5%（151/299），每周进行≥2次血糖自我监测者占26.4%（79/299）；空腹血糖达标率为49.8%(149/299)，餐后2 h血糖达标率为58.2%（174/299），HbA1c达标率为38.1%(114/299),低血糖发生率为28.8%（86/299）。299例随访患者中232例（77.6%）能够合理荤素搭配饮食，270例（90.3%）患者能够坚持每周进行≥3次、每次40～60 min有氧运动，287例（96.0%）规律使用降糖药物治疗。社区卫生服务中心每月进行慢性病健康教育知识讲座3～4次，每年专家进小区进行慢性病宣教4～5次。结论    北京市大屯社区2型糖尿病患者在定期血生化检验、饮食、体育锻炼、用药依从性方面表现良好；空腹血糖、餐后2 h血糖达标率较好，而HbA1c达标率不理想；糖尿病患者建档率及血糖自我监测方面仍有较大差距。

• 【Abstract】Objective    To investigate the current control and management status of type 2 diabetes in a community health center in Beijing; to understand the advantages and disadvantages of community management for diabetes and carry out targeted rectification. Methods    From January 1st, 2017 to December 31st, 2017, a cross-sectional study was conducted on 604 patients with type 2 diabetes who continuously visited Beijing Datun Community Health Center. General information of patients was collected through the consultation system and chronic disease management system. Patients′ self-monitoring of blood glucose, frequency of hypoglycemia, exercise, diet, medication compliance and health education of diabetes were followed up by telephone during 1 year. Results    Among the 604 patients, 153 cases had diabetes chronic disease records and the filing rate was 25.3%. Final telephone follow-up was completed in 299 cases(49.5%) and 2 cases of them died. Among the follow-up patients, 89.3%(267/299) underwent blood biochemical test at least once per year; 50.5%(151/299) underwent at least twice of glycosylated hemoglobin(HbA1c) test per year; 26.4%(79/299) underwent regular self-blood glucose test(≥2 times per week). The compliance rate of fasting blood glucose was 49.8%(149/299); the compliance rate of 2 h postprandial blood glucose was 58.2%(174/299); the compliance rate of HbA1c was 38.1%(114/299); the incidence rate of hypoglycemia was 28.8%(86/299). During follow-up, 232 patients(77.6%) were able to match the diet; 270 patients(90.3%) could insist on aerobic exercise more than 3 times a week for 40-60 minutes; 287 patients(96.0%) regularly used antidiabetic drugs. Community health center conducted health education knowledge lectures 3-4 times a month and invited experts for chronic disease education 4-5 times a year. Conclusions    Type 2 diabetic patients in Beijing Datun community perform well in regular blood biochemical test, diet control, physical exercise and medication compliance; fasting blood glucose and 2 h postprandial blood glucose can reach the standards, while the level of HbA1c is not optimistic. There are still gaps of filing rate and self-monitoring in diabetic patients.