摘要目的:评价全科医生指导下社区糖尿病患者自我管理模式的效果。方法:2016—2017年选取杭州市22个社区作为干预试点，各招募10~15例糖尿病患者组建自我管理小组。依托医联体建设及家庭医生签约服务资源，组建干预团队，对患者定期进行个性化、连续性的自我管理干预，干预持续约4~6个月。在干预前、后及干预后6个月通过问卷调查收集患者基本信息、知信行、自我管理能力及生活质量等情况，统一检测体质指数（BMI）、餐后2 h血糖及糖化血红蛋白，进行统计分析。结果:参与自我管理小组的患者共计292例，年龄（66.38±7.90）岁，女性居多（64.73%）。干预后6个月患者基本知识、危险因素、防治知识的知晓率（68.64%、78.75%、63.41%）较干预前（28.08%、48.29%、39.38%）明显提高，合理膳食、适度运动、主动解决问题、制定管理计划及根据计划采取行动的患者比例提高，由干预前的65.41%、28.76%、39.04%、31.85%、27.74%上升至干预后6个月的86.76%、60.28%、65.16%、78.05%、73.17%）（均 P<0.05）。在时间效应上，干预后、干预后6个月健康调查简表（SF-36）的生理功能、生理职能、躯体疼痛、总体健康、精力、社会功能、情感职能、精神健康维度得分均逐次升高（均 P<0.05）。干预前患者BMI、餐后2 h血糖、糖化血红蛋白分别为（24.20±3.11） kg/m 2、（9.29±2.23） mmol/L、（6.81±1.01）%，干预后6个月分别降至（22.89±2.98） kg/m 2、（8.81±1.61） mmol/L、（6.57±0.76）%（ F=14.832，6.828，9.667；均 P<0.05）。 结论:全科医生指导下社区糖尿病患者自我管理模式可有效改善患者的知信行水平，提高患者自我管理能力及生活质量，改善BMI及血糖控制水平。

abstractsObjective:To evaluate the effect of self-management model of community diabetes patients under the guidance of general practitioners.Methods:A total of 22 communities in Hangzhou were selected as intervention pilot from 2016 to 2017, and 10-15 diabetic patients were recruited to form a self-management team in each community. Relying on the construction of medical alliance and there sources of contracted service of family doctors, intervention teams were set up to conduct regular, personalized and continuous self-management interventions on patients. Intervention continued for 4-6 months. Before, after and 6 months after the intervention, the basic information of patients, knowledge of diabetes, faith in managing disease, self-management behavior, self-management ability of patients, and quality of life were collected through questionnaire survey, body mass index (BMI), 2-hour postprandial blood glucose and glycosylated hemoglobin were detected uniformly, and statistical analysis was conducted.Results:A total of 292 patients were involved in the self-management group, the average age was (66.38±7.90) years old, most of them were female (64.73%). Six months after the intervention, the awareness rate of basic knowledge, risk factors and prevention and treatment knowledge about diabetes in patients (68.64%, 78.75%, 63.41%) were significantly higher than those before the intervention (28.08%, 48.29%, 39.38%), the proportion of patients with reasonable diet, moderate exercise, active problem-solving, management plan making and action according to the plan increased (from 65.41%, 28.76%, 39.04%, 31.85%, 27.74% to 86.76%, 60.28%, 65.16%, 78.05%, 73.17%)(all P<0.05).In terms of time effect, the scores of physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional and mental health in SF-36 after intervention and 6 months after intervention were all increased step by step (all P<0.05). Before the intervention, BMI, 2-hour postprandial blood glucose and glycosylated hemoglobin were (24.20±3.11) kg/m 2, (9.29±2.23) mmol/L, (6.81±1.01)% respectively. After the intervention, the three indexes all showed a downward trend, which were (22.89±2.98) kg/m 2, (8.81±1.61) mmol/L, (6.57±0.76)% respectively ( F=14.832, 6.828, 9.667; all P<0.05). Conclusion:Under the guidance of general practitioners, the self-management model of community diabetes patients can effectively improve the level of recognition, belief and behavior of patients, improve their self-management ability and quality of life, and improve BMI and blood glucose control level.