| Background and purposeIn recent years,the prevalence of type 2 diabetes mellitus has been increasing in our country,which is the main cause of blindness,cardiovascular and cerebrovascular events,renal failure and amputation in our country.The task of prevention and treatment of diabetes at the grass-roots level in our country is very arduous,and the level of health management needs to be improved urgently.The management service of diabetes at the grass-roots level should rely on the system of family doctors.In 2016,the State Council Medical Reform Office and seven other ministries and commissions issued the notice on issuing guidance opinions on promoting family doctor contracted services(issued by the State Medical Reform Office(No.1,2016)),and began to carry out a comprehensive contracted family doctor services(hereinafter referred to as "the services").Under the background of a general practice plus compact regional medical community,this study takes contracted family doctor services for type 2 diabetes mellitus(T2DM)patients as the research object,to investigate the supply and demand sides.This study analyzed the quality of the services from the aspects of blood glucose control rate and self-management behavior score,and through patient evaluation and demand of the services,to analyzed of the status quo of services supply.Furthermore,the study also explored the barriers and facilitators of the implementation of the services.The purpose is to explore the advantages and problems of the services under the background of the medical community,provide inspiration for the improvement of the services,and to promote the management of type 2 diabetes in this town.MethodsThis study adopts the method of quantitative and qualitative combination,using convenient sampling method for questionnaire survey.The questionnaire consists of four parts:General Information,disease status,summary of diabetes self care activities(C-SDSCA),The scale has five dimensions:diet management,foot care,blood glucose monitoring,exercise management and medication management.The Cronbach’s α coefficient of the Chinese version of the scale was 0.840.Cronbach’s a of all dimensions ranged from 0.62-0.92.Other parts of the questionnaire were selfconstructed by the research team based on discussions on group meetings.A convenient sampling method was used to conduct qualitative interviews with medical personnel who were engaged in the services.Based on the theoretical domains framework(TDF),an interview outline was designed to explore barriers and facilitators in implementing the services.Quantitative data was inputted by Excel data sheet and analyzed by SPSS 26.0 software.The quantitative data were expressed as(mean ± standard deviation)and the counting data as relative numbers.Statistical methods such as one-way analysis of variance,multiple linear regression and logistics regression analysis were used to analyze the quantitative data.P<0.05,the difference was statistically significant.In the part of qualitative research,we transcribed the interview verbatim to form the transcript,and imported the transcribed data into Nvivo 11.0 qualitative data analysis software.Thematic data analysis method was applied to analyze interview data.ResultsA total of 298 valid questionnaires were obtained in the quantitative study.The results showed that the overall standard score of self-management capacity was 55.42±15.69,which was in the middle level.Self-management behavior was good in 16 cases(5.37%),moderate in 235 cases(78.86%)and poor in 47 cases(15.77%).A univariate analysis found that,the scores of self-management behavior were significantly different in sex,payment mode of medical expenses,whether there were chronic complications of diabetes,whether the target of fasting blood glucose,whether the target of 2-hour postprandial blood glucose(P<0.05).The results of multiple linear regression suggested that the presence or absence of diabetic complications was an influential factor in the score of self-management behavior in T2DM patients,explaining 5.4%of the total variance(P<0.05),and the level of selfmanagement ability was lower in patients with diabetic complications than in those without chronic complications.The medical services for T2DM patients contracted by the community include diabetes health management services(health education,medication guidance,etc.),diabetes diagnosis and treatment,health check-up,regular follow-up," prescription”preferential services,assessment of health status,establishment of health records and referral booking,etc.Further services required included Chinese medicine physiotherapy and health care,rehabilitation services,home care,home beds,remote health monitoring,community outpatient infusion,family pharmacist services,etc.In the qualitative study,18 barriers in 8 domains and 20 promoting factors in 13 domains were extracted.From the point of view of medical personnel,the services benefit patients,medical personnel,organizations and society,and they have the general knowledge and skills to carry out the services and are willing to carry out the contract services and so on,but at the same time,there are also some obstacles such as insufficient financial input,publicity and integration of information resources.ConclusionThe content of existing the contracted family doctor services is more comprehensive,and patients are satisfied with the services,but the services demand is diversified,personalized services needs to be further optimized.Patients with low fasting blood glucose control rate,need to strengthen self-management education and guidance.In terms of services subjects,there are some problems such as the insufficient number of general practitioners,the lack of participation of specialist doctors in the team,the heavy workload,and the lack of corresponding increase in salary,etc.Therefore,it is necessary to strengthen the services team building,improve the performance appraisal and incentive system.Besides,the implementation of two-way referral system is not in place,so it is necessary to optimize the process of medical treatment and referral,and encourage communities and hospitals to standardize referral.Furthermore,resource investment should be increased,and multi-party publicity and information platform construction should be accelerated to further play the advantage of the general practice plus compact regional medical community,integrating medical resources and improve the quality of contract services. |
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