目的: 探讨互联网+“三一照护”模式在糖尿病居家管理中的应用效果。方法: 选取2020年3月至2021年10月就诊的892例2型糖尿病患者,依托互联网血糖管理平台移动端,由“三一照护”团队进行全程管理,采用糖尿病相关知识认知与行为问卷调查表、自我管理能力调查量表,分别在管理前和管理6个月、12个月进行采集评定,同时比较血糖、血压达标率和空腹血糖、餐后2小时血糖、糖化血红蛋白、血脂、尿白蛋白/肌酐等代谢指标在管理前后的变化。结果: 管理6个月、12个月与管理前相比,患者糖尿病相关知识的认知和行为得到提高,并随着管理时间的延长不断提高(P＜0.05);饮食控制、规律运动、用药依从性、血糖检测、并发症管理及量表总得分均得到改善(P＜0.05),管理12个月较管理6个月在饮食控制、规律运动、并发症管理方面得到进一步改善(P＜0.05);血糖、血压达标率管理后明显提高,并随时间的推移进一步提高(P＜0.05);空腹血糖、餐后2小时血糖、糖化血红蛋白、血脂、尿白蛋白/肌酐管理后均有明显下降(P＜0.05),管理12个月较6个月空腹血糖、糖化血红蛋白、尿白蛋白/肌酐得到持续改善(P＜0.05)。结论: 通过互联网+“三一照护”模式对2型糖尿病患者居家管理,患者自我管理意识、管理行为不断增强,血糖、血脂、尿白蛋白/肌酐等代谢指标得以改善,达标率增高,新的管理模式应用大大提升了慢病管理水平。

Objective: To explore the application effect of the Mobile Internet & Unified-Diabetes-Care model in the home management of diabetes.Methods: A total of 892 patients with type 2 diabetes who received medical treatment from March 2020 to October 2021 were selected for whole-process management by the Unified-Diabetes-Care team relying on the mobile terminal of the Internet blood glucose management platform.The questionnaire on cognition and behavior of diabetes-related knowledge and the self-management ability survey scale were used for collection and evaluation before and 6 and 12 months after management, respectively.At the same time, the changes of fasting blood glucose, blood glucose 2 hours after meals, glycosylated hemoglobin, blood lipid, urinary albumin/creatinine and other metabolic indexes before and after management were compared.Results: After 6 months and 12 months of management, the cognition and behavior of diabetes-related knowledge were improved compared with that before management, and increased with the extension of management time (P＜0.05).Diet control, regular exercise, medication compliance, blood glucose detection, complication management and scale total score were improved (P＜0.05), and the diet control, regular exercise and complication management were further improved after 12 months compared with 6 months of management (P＜0.05).The up-to-standard rates of blood glucose and blood pressure were significantly increased after management, and further increased with the passage of time (P＜0.05).Fasting blood glucose, 2 hours postprandial blood glucose, glycosylated hemoglobin, blood lipid, urinary albumin/creatinine were significantly decreased after management (P＜0.05), and fasting blood glucose, glycosylated hemoglobin, urinary albumin/creatinine were continuously improved after 12 months of management compared with 6 months of management (P＜0.05).Conclusion: Home management of type 2 diabetes patients through the Mobile Internet & Unified-Diabetes-Care model has continuously enhanced the self-management awareness and management behavior of patients, improved the metabolic indicators such as blood sugar, blood fat, urinary albumin/creatinine, and increased the standard compliance rate.The application of the new management model has greatly improved the level of chronic disease management.