New Urban Medical Service System Management Type2Diabetes Research

Objective: We dynamic observe patients with type2diabetes blood sugar，blood fat and blood pressure changes in the diabetic management system byfamily-community-hospital3ranks seamless management mode. Find someexperience for type2diabetes mellitus patients control standards by‘ChineseType2Diabetes Prevention Guide (2010)’.Methods: Relying on Guilin local medical system，and establish a healtheducation as the main body of the family-community-hospital3ranks seamlessmanagement mode. The full management mode follows. Endocrinology Doctorguides medical personnel in community health center to establishment of T2DMeducation management team，and common to manage the community diabetespatients. To the hospital as a guide，the community health center on the basis of‘Diabetes Hierarchical Management’separate different patients to differenttreatment，some patients need to hospital treatment by the community to fill in‘Referral Card’，and recommend they treatment in hospital，after dischargefrom hospital referral to community to continue management；Establish threeinterrelated management network，through the chat on line system and telephonemake family，community and hospital contact each other，regularly give patients a medical examination，then the medical condition assessment，each quarter ofpatients were followed up for the community；Guilin Hearth Bureau shall beresponsible for the organization，guidance and coordination work，give policyand financial resources support. On the Diecai and Nanmen community，patientswith type2diabetes in21months of diabetes3ranks seamless managementmode has been managed by health education，centralism teaching，regularreview，telephone follow-up and collective activities. In different period toobserve the patient’s blood sugar，blood fat and blood pressure dynamic change.Results: Patients fasting plasma glucose (FPG) first decreases，raised，thengradually decreased；After dinner2hours plasma glucose (2hPG) participate inthe administration of after gradually reduce；Hemoglobin A1c (HbA1c) togradually reduce，then gradually increase；Triacylglycerol (TG) although haveups and downs，but gradually decreased；Low Density Lipoprotein (LDL) inJune and December is higher，large fluctuations；High Density Lipoprotein(HDL) to gradually reduce，then slightly rebounded；Systolic Blood Pressure(SBP) and Diastolic Blood Pressure (DBP) reduced significantly，and low levelfluctuation.Conclusions:2hPG control is FPG and HbA1c improved， HbA1cmanagement improvement is obvious in6months，then gradually raised. BloodSugar long-term management need to strengthen. We need to encourage patientsto strengthen Self Management of Blood Glucose (SMBG)，improve glycemiccontrol in patients with smooth, to achieve‘Chinese Type2Diabetes PreventionGuide (2010)’control standards. Blood Lipoids control not beautiful，in additionto diabetes lead to dyslipidemia，still with the local residents like the high fatdiet habits，especially on holidays food of high quantity of heat more food. We should strengthen the diabetes Blood Lipoids adjusting treatment，and properdrug control Blood Lipoids. Blood pressure management improved obviously.But the percentage of blood pressure is only about50%，in the managementshould also strengthen the control of blood pressure of education，encouragepatients movement，the control diet，control has been the ideal drug improvesuccess rate.