| Objective:In order to explore the different risk factors of diabetes patients grouped,and combined with tertiary hospitals for individual management effect and its model in community diabetes management is worth promoting and studying.Methods:Based on the estimated glomerular filtration rate(eGFR)level and 8 risk factors(obesity,dyslipidemia,hypertension and diabetes mellitus),38 patients with type 2 diabetes who were contracted by Liuyuan Street Community Health Service Center in Gusu District of Suzhou City from October to December 2015 were treated by general practitioner-led,general practitioner nurses and specialists.Disease retinopathy,urinary protein creatinine ratio,foot disease,glycosylated hemoglobin Alc,fasting blood glucose or non-fasting blood glucose were divided into low risk group(3 cases),medium risk group(11 cases),high risk group(21 cases)and extremely high risk group(3 cases),referring to the risk stratification of Asian Diabetes Joint Assessment(JADE).Bachelors and specialists form a management team to conduct case management aiming at reducing controllable risk factors and complications according to patients'needs.The changes of BMI,eGFR,TC,LDL-C,FPG and HbA1c levels after 1 year of management(March 7,2016 to February 24,2017)were observed.Results:BMI,TC and LDL-C levels in low-risk group were lower than those before management,but there was no significant difference.Fasting blood sugar,HbAlc and eGFR increased,but there was no significant difference.BMI and eGFR levels in the middle-risk group and the high-risk group were improved after management,but there was no significant difference.The levels of TC,LDL-C,fasting blood sugar and HbA1c were significantly decreased(P<0.05),and the levels of LDL-C in high-risk group were significantly decreased(P<0.01).The levels of TC,LDL-C and fasting blood glucose in the extremely high risk group were lower than those before management,and the difference was statistically significant(all P<0.05). |
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