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 observe the effect of community-hospital integrated model on diabetes management.Methods From 2004 to 2009,701 patients with diabetes were selected from Zhonghua and Xiagang community health centers and managed with the community-hospital integrated management model.Their blood glucose levels and changes of lifestyle were compared between before and at the end of the management.Results The levels of fasting blood glucose [(6.9±1.7)mmol/L] and 2 h postprandial blood glucose[(9.0±2.0) mmol/L] at the end of 2 years management were significant lower that those[(7.6±2.3) mmol/L and (9.9±2.5) mmol/L ]before the management.And there was a declining trend of the fasting blood glucose and 2 h postprandial blood glucose with the time of the management.The lifestyle of them,including salt restriction,exercise,alcohol drinking restriction and body weight control,was improved significantly (P<0.01).Conclusion The community-hospital integrated management model for diabetes plays an ideal role on the management and control of diabetes in communities
