网络医院对糖尿病患者延续健康随访管理的方法与实施效果

目的：探讨通过网络医院健康管理平台，对使用胰岛素治疗的2型糖尿病患者实施出院后延续性健康管理的效果。方法对48例使用胰岛素治疗的2型糖尿病患者实施延续性健康管理，住院期间均接受胰岛素使用个体化教育，出院后接受网络医院延续健康随访管理，3个月后比较患者管理前后胰岛素使用依从性、胰岛素使用知识与注射操作、糖尿病综合管理能力得分、空腹血糖、糖化血红蛋白。结果干预后48例患者的胰岛素使用依从性、注射技能及使用知识、糖尿病综合管理能力得分分别为（7．35±0．95），（82．52±8．54），（117．47±12．42）分，均高于干预前的（6．49±1．52），（56．54±10．93），（80．86±15．71）分，差异有统计学意义（t值分别为4．9559，14．0038，13．6396；P＜0．01）。干预后48例患者的空腹血糖、糖化血红蛋白分别为（6．20±0．85）mmol/L，（6．56±0．91）％，均低于干预前的（8．53±2．16）mmol/L，（8．73±1．72）％，差异有统计学意义（t值分别为5．9857，9．0039；P＜0．01）。结论通过网络医院对胰岛素使用的2型糖尿病患者进行出院后延续的随访管理，可显著提高2型糖尿病患者的胰岛素使用依从性与注射技能、使用知识，能更好地建立患者自我管理行为、有利于患者的血糖控制。

Implementation effect of the continuity health fullow-up management in diabetic patients through network hospital

Objective To explore the establishment of the health management platform through network hospital, and to investigate the effect of the implementation of the continuity health management after discharge on the type 2 diabetes mellitus patients with the use of insulin .Methods Forty-eight type 2 diabetes mellitus patients with the use of insulin received the continuity health management , and individualized education of the use of insulin during the hospital and the continuity health follow-up management through network hospital after discharge.The scores of the compliance , knowledge and injection practice of the use of insulin , the comprehensive ability of management diabetes , and the levels of fasting blood glucose （FBG） and HbA1c were compared in patients 3 months after the intervention .Results The scores of the compliance , knowledge and injection practice of the use of insulin , the comprehensive ability of management diabetes were respectively （7.35 ±0.95）, （82.52 ±8.54）, （117.47 ±12.42） after the intervention, and were higher than （6.49 ± 1.52）, （56.54 ±10.93）, （80.86 ±15.71） before the intervention, and the differences were statistically significant （t=4.955 9, 14.003 8, 13.639 6, respectively;P〈0.01）.The levels of FBG and HbA1c were respectively （6.20 ±0.85） mmol/L, （6.56 ±0.91） % after the intervention, and were lower than （8.53 ± 2.16）mmol/L, （8.73 ±1.72）% before the intervention, and the differences were statistically significant （t=5.985 7,9.003 9, respectively;P 〈0.01 ） .Conclusions The implementation of the continuity follow-up management through network hospital after discharge in type 2 diabetes mellitus patients with the use of insulin can significantly improve the compliance , knowledge and injection practice of the use of insulin in patients , and establish patients ’ self-management action well so as to help them control glucose .