【作者】 谢珺；

【导师】 卢祖洵；

【作者基本信息】 华中科技大学 ， 老年医学， 2013， 博士

【摘要】 研究目的通过文献研究和现场调查，掌握我国糖尿病防治能力与管理模式现状及开展的效果，研究分析我国基层卫生服务机构糖尿病防治能力、管理模式和机制以及相关经验与问题，深入剖析各地没有糖尿病等慢性病系统管理的原因和实施障碍，为构建糖尿病及其他慢性病的管理模式、机制及支持系统和提高中国基层卫生服务机构的糖尿病防治能力提供政策建议。研究方法本研究采取定性研究和定量研究相结合的方式进行，具体方法包括文献荟萃、问卷调查、专题组访谈和案例分析等。设计糖尿病管理基本情况调查表，通过函调和现场填写等方式回收问卷，现场访谈同时收集文件、制度、总结等现成资料，了解各地糖尿病管理的现状和问题、工作模式和机制以及相关的建议和意见等。对各地具有特色的糖尿病管理模式和机制进行案例研究，深入了解糖尿病管理的具体模式、工作机制和支持系统等情况。应用Epidata3.1软件进行录入数据，应用Excel2000、SPSS13.0以及SAS8.12等专业统计软件进行统计分析。研究结果1、机构建设情况。城市社区卫生服务中心和乡镇卫生院的业务用房平均面积分别为2469.25平方米和2553.56平方米，均超过国家建设标准。中心的住院病床平均为34.49张，观察床平均为5.18张。卫生院住院病床平均为24.10张，观察床平均为4.93张。2、卫生人力资源配置情况。城市社区卫生服务中心临床医生中研究生学历占2.94%，本科占31.3%，专科占36.54%，中专占21.64%，其余为中专以下学历，占7.54%。防保人员学历以专科为主，占42.99%，其次为中专学历，占28.60%，本科为18.17%，研究生为0.90%，中专以下占9.56%。护士学历以中专为主，占45.55%，其次为专科，占41.25%，中专以下占6.55%，本科为5.42%，另外，研究生学历占1.23%。城市社区卫生服务中心临床医生职称以初级职称为主，占51.58%，其次是中级职称，占35.99%，高级职称为12.43%。防保人员职称以初级职称为主，占63.92%，中级职称为28.94%，高级职称仅为1.65%，另外，无职称为5.49%。护士职称也以初级职称为主，占71.82%，中级为26.74%，高级职称仅为1.43%。在农村乡镇卫生院，临床医生学历以专科和中专为主，分别为43.73%和38.92%，其次为本科学历，占12.68%，其余为中专以下学历，站4.68%。防保人员学历以中专为主，占48.88%，其次为专科，占36.06%，中专以下占11.90%，本科仅为3.16%。护士学历也以中专为主，占58.37%，其次为专科，占34.52%，中专以下占5.54%，本科仅为1.57%。卫生院临床医生职称以初级职称为主，占58.82%，其次是中级职称，占32.68%，高级职称为3.47%，无职称占5.04%。防保人员没有高级职称，其中初级职称占71.85%，中级职称为20.37%，另外，无职称为7.78%。护士的职称以初级职称为主，占63.03%，中级职称为30.88%，无职称为5.98%，高级职称仅为0.11%。以上数据显示，我国城乡基层卫生服务机构卫生人力的学历和职称水平都偏低，并且表现为农村差于城市。3、慢性病管理资源配置情况。在管理配套上，配有专门的慢性病管理办公室的城市社区卫生服务中心占91.53%，所有中心都配有专门用于慢性病管理的计算机，平均拥有的计算机为3.07台。有96.61%的中心建立了慢性病管理数据库（包括糖尿病数据库），但管理系统稳定性还不太理想，正常率为57.89%。配有专门的慢性病管理办公室的乡镇卫生院占64.55%，配有专门的慢性病管理计算机的卫生院占51.82%，卫生院平均拥有的计算机为1.45台。只有32.73%的卫生院建立了慢性病管理数据库（包括糖尿病数据库），管理系统运行基本正常，正常率为97.22%。乡镇在糖尿病管理配套上较城市落后，资源数量少于城市。关于糖尿病检测和治疗工作的开展情况，调查的城市社区卫生服务中心均可以开展糖尿病检测工作，都配有血糖仪，另外配有生化分析仪、尿糖试纸检测的中心分别为79.66%和77.97%。能开展糖尿病治疗的中心占96.61%。药房配有磺脲类促胰岛素分泌剂、非磺脲类促胰岛素分泌剂、双胍类、糖苷酶抑制剂、胰岛素增敏剂、胰岛素、降糖中成药的中心分别占84.48%、75.86%、96.55%、60.34%、53.45%、75.86%、79.31%。然而，在乡镇，能开展糖尿病检测的卫生院占92.73%。具有血糖仪、生化分析仪、尿糖试纸检测的卫生院分别为90.20%、70.59%和59.80%。能开展糖尿病治疗的卫生院占89.91%。药房配有磺脲类促胰岛素分泌剂、非磺脲类促胰岛素分泌剂、双胍类、糖苷酶抑制剂、胰岛素增敏剂、胰岛素、降糖中成药的卫生院分别占47.57%、11.76%、82.35%、8.82%、15.53%、48.54%、63.11%。本组数据提示，城市社区卫生服务中心糖尿病检测相关仪器和治疗药品的配置相对齐全，具备提供糖尿病治疗的基本条件。而乡镇卫生院则存在部分机构缺乏检测能力和治疗药品，导致存在无法提供糖尿病检测和治疗的情况。4、糖尿病管理实施情况。在城市社区卫生服务中心，已经进行糖尿病社区筛查的中心占93.22%，2009-2010年度中心平均举办的糖尿病健康教育讲座为7.03次，绝大部分中心都定期开展病人健康教育，占98.31%，定期复查血糖或糖化血红蛋白的中心占86.44%，督导患者服药的卫生院占96.61%，对患者及家属进行健康教育或技能培训的中心占94.92%，建立患者健康档案的中心占100.00%，开展患者家庭访视98.31%，开展糖尿病社区健康促进活动的中心占91.53%，开展并发症监测的中心占55.1%。在乡镇卫生院，已经进行糖尿病社区筛查的卫生院占65.45%，其中摸清糖尿病患者的卫生院32.73%。2009-2010年度，卫生院平均举办的糖尿病健康教育讲座为2.79次，定期开展病人健康教育的卫生院占67.27%，定期复查血糖或糖化血红蛋白的卫生院占70.91%，督导患者服药的卫生院占81.82%、对患者及家属进行健康教育或技能培训的卫生院占82.73%、建立患者健康档案的卫生院占86.36%、开展患者家庭访视81.82%、开展糖尿病社区健康促进活动的卫生院占60.91%、开展并发症监测的卫生院占41.28%。比较可见，城市的糖尿病管理实施情况要优于乡镇的。5、糖尿病管理模式。主要模式有团队服务模式和中心（院）与站（室）分工合作模式。前者包括全中心（院）参与模式、慢性病工作组模式、慢性病督导管理模式；后者主要包括中心（院）主导，站（室）协助完成式、中心（院）和站（室）共同主导完成式、中心（院）组织，站（室）主导完成式以及中心（院）独自完成式。6、基层医务人员糖尿病培训情况及其对防治工作的意愿。城乡基层医生一致认为现有专业培训次数少、内容不足。关于“对目前糖尿病防治工作是否满意”，52.04%的社区卫生服务中心调查对象表示“一般”，40.14%表示“很满意”或“较满意”，7.82%表示“不满意”或“很不满意”；乡镇卫生院调查对象中，54.82%表示“一般”，37.56%表示“很满意”或“较满意”，7.61%表示“不满意”或“很不满意”。研究结论1、中国基层糖尿病防治网络体系基本建立，总体上表现为基层卫生服务机构糖尿病防治能力不足。但从人力资源、硬件配套和投入经费等方面比较，显示出城市糖尿病防治能力要强于农村。2、部分管理层对糖尿病防治的重视程度不够，影响了基层卫生服务机构糖尿病防治能力的提升。3、基层卫生人才队伍整体素质不高，糖尿病防治与管理的专业知识匮乏，因此表现为对糖尿病的防治和管理力不从心。4、针对基层卫生服务机构糖尿病知识和技能的培训工作滞后，影响了医务人员防治水平的提升。5、糖尿病没有专项的防治经费，现有的防治工作经费主要来自公共卫生经费，而且数额很少，对糖尿病防治工作支持力度有限。6、基层糖尿病管理的信息系统建设呈现不均衡态势，但城市要好于农村。7、居民健康意识较差，对糖尿病防治工作参与度和配合度不强，成为糖尿病防治工作要解决一个问题。创新与局限本研究首次在全国范围内调查我国城乡基层卫生服务机构糖尿病等慢性病管理开展的现况，分析基层卫生服务机构的糖尿病防治能力，为进一步完善我国基层糖尿病防治管理的网络体系和提高防治能力提出改进方案和策略。本研究运用系统论、资源配置等的理论从宏观角度来探讨我国基层卫生服务机构的糖尿病防治能力，具有创新性。本研究的不足之处和局限性表现为，研究仅从组织结构系统和资源配置的角度对基层卫生服务机构的糖尿病防治能力进行了分析，未收集现有资源情况下体现防治成效的有关数据，因而不能更精确的掌握与提高基层糖尿病防治能力有关的更多信息。今后可以更进一步的开展相关研究。更多还原

【Abstract】 ObjectiveWe aimed to grasp the ability of diabetes prevention and control, the mode ofmanagement, and the effct of diabetes prevention and control in primary health careinstitutions of China, by means of literature research and field survey. Then weexplored the experience and problems, and analyzed the reasons and barriers ofdistricts lacking System Management of diabetes and other chronic diseases.Consequently we tried to put forward specific policy recommendations forconstructing mode of management, mechanisms, and support systems to improve theability of diabetes prevention and control in primary health care institutions of China.MethodsThis study is a combination of qualitative and quantitative research, the specificmethod including meta-literature, questionnaires, focus group interviews and casestudies. Design diabetes management questionnaire by letter reconcile site fillquestionnaires, on-site interviews while collecting file system, a summary of readilyavailable information about diabetes management around the current situation andproblems, operating modes and mechanisms and the related recommendations andopinions and so on. Around the distinctive patterns and mechanisms of diabetesmanagement case studies, in-depth understanding of the specific mode of diabetesmanagement, working mechanisms and support systems. Application Epidata3.1software for data entry, application the Excel2000SPSS13.0and SAS8.12professional statistical software for statistical analysis. Results1. institution-building. Urban community health service centers and townshiphospitals, business houses average area of2469.25square meters and2553.56squaremeters, exceeding the national building standards. Center inpatient beds an average of34.49and bed and an average of5.18. The hospitals inpatient beds an average of24.10and bed and an average of4.93.2. The configuration of human resources for health. Graduate degree in urbancommunity health service center clinicians accounted for2.94%,31.3%undergraduate, the specialist accounting for36.54%, secondary accounted for21.64%,and the rest for the following secondary education, accounting for7.54%. Preventionand care staff education specialist, accounting for42.99%, followed by secondaryeducation, accounting for28.60%,18.17%undergraduate, graduate of0.90%,accounting for9.56%of the following secondary. Nurses’ qualifications in secondary,accounting for45.55%, followed by the specialist, accounting for41.25%, secondaryschool accounted for6.55%,5.42%undergraduate, postgraduate education accountedfor1.23%. Urban community health service center clinicians titles junior titles,accounting for51.58%, followed by intermediate grade, accounting for35.99%,12.43%senior title. Anti-Paul Designation of junior titles, accounting for63.92%,intermediate grade of28.94%senior titles, only1.65%,5.49%titles. Nurse titlesjunior titles, accounting for71.82%,26.74%intermediate, senior titles of only1.43%.In rural township hospitals, clinicians education specialist and secondary,43.73%and38.92%, respectively, followed by a bachelor’s degree, accounting for12.68%, the restis secondary degree, stand4.68%. Anti-assurance personnel qualifications tosecondary, accounting for48.88%, followed by the specialist, accounting for36.06%,secondary school accounted for11.90%, the undergraduate only3.16%. Nurses’qualifications in secondary, accounting for58.37%, followed by the specialist,accounting for34.52%, accounting for5.54%of the following secondary,undergraduate only1.57%. Hospitals the clinicians titles to junior titles, accounting for58.82%, followed by intermediate grade, accounting for32.68%,3.47%seniorprofessional titles, titles accounted for5.04%. Prevention and care do not have seniorprofessional titles, which accounted for71.85percent of junior titles, intermediategrade of20.37%,7.78%titles. Nurse’s title to the junior titles, accounting for63.03%,intermediate grade of30.88%, the No Title5.98%, the senior title only0.11%. Theabove data show that China’s urban and rural primary health services of the healthworkforce qualifications and title levels are low, the performance of the rural poor inthe city.3. Allocation of resources of chronic disease management. Management supporting,with specialized chronic disease management office of the city community healthservice centers accounted for91.53%of all centers with specialized computer forchronic disease management, computer an average of3.07units.96.61%of thecenters of the chronic disease management database (including diabetes database), butthe management system stability is not yet ideal, the normal rate of57.89%. Withspecialized chronic disease management office of township hospitals accounted for64.55%, with specialized chronic disease management computer hospitals accountedfor51.82%of hospitals have an average computer1.45. Only32.73%of the hospitalsestablished chronic disease management database (including diabetes database)management system normal operation, the normal rate of97.22%. Township in thecity behind, supporting diabetes management than the amount of resources than in thecities.About diabetes detection and treatment work carried out, the survey of urbancommunity health service center can carry out the diabetes testing work, with a bloodglucose meter, the other with a biochemical analyzer, the center of the urine dipsticktest were79.66%and77.97%.Center to carry out the treatment of diabetes accounts for96.61%. Pharmacy withsulfonylurea agents on insulin secretion, non-sulfonylurea insulin secretagogues,biguanides, glucosidase inhibitors, insulin sensitizers, insulin, hypoglycemicproprietary Chinese medicine centers accounted for84.48%,75.86%,96.55%,60.34%,53.45%,75.86%,79.31%. However, in villages and towns, the diabetes detection hospitals accounted for92.73%. Blood glucose meter, biochemical analyzer,urine dipstick hospitals were90.20%,70.59%and59.80%, respectively. To carry outthe treatment of diabetes hospitals accounted for89.91%. Pharmacy with sulfonylureaagents on insulin secretion, non-sulfonylurea insulin secretagogues, biguanides,glucosidase inhibitors, insulin sensitizers, insulin, hypoglycemic proprietary Chinesemedicine hospitals accounted for47.57%,11.76%,82.35%,8.82%,15.53%,48.54%,63.11%. The data suggest that the urban community health service centers diabetesdetection instruments and drugs for the treatment configuration is complete, with thebasic conditions of diabetes treatment. Township hospitals, there are some institutionslack of detection capabilities and treatment drugs, leading to the presence unable toprovide the detection and treatment of diabetes.4. Implementation diabetes management. Community health service centers in the city,has been the center of the diabetes community screening accounted for93.22%2009-2010annual average of organized diabetes health education seminars to7.03,most of the centers regularly carry out health education for patients, accounting for98.31%, the center of the regular review of blood glucose or glycated hemoglobinaccounted for86.44%of the medication in patients with Steering hospitals accountedfor96.61%, accounted for94.92%of the patients and their families health educationor skills training center, the establishment of the center of the patient’s health recordsaccounting for100.00%, to carry out the patient home visits98.31%, to carry outhealth promotion activities center accounted for91.53%of the diabetes community, tocarry out the center of the complications monitoring55.1%.32.73%of the hospitalsin township hospitals, screening for diabetes community hospitals accounted for65.45%, find out the diabetes.2009-2010, hospitals holds an average of diabeteshealth education seminars for2.79, regularly carry out health education for patients ofhospitals accounted for67.27%of the regular review of blood glucose or glycosylatedhemoglobin hospitals accounted for70.91percent of hospitals accounted formedication in patients with Steering hospitals accounted for81.82%of the patientsand their families health education or skills training hospitals accounted for82.73%, the creation of patient health records of hospitals accounted for86.36%,81.82%visitsto carry out the patient’s family, the diabetes community health promotion activities60.91%, accounted for41.28%of hospitals to carry out the monitoring ofcomplications. More visible, the city’s diabetes management the implementation issuperior to the township.5. The model of diabetes management. The main mode of team service model andcenter (hospital) and Station (room) division of labor. The former includes Center(hospital) participation model, chronic diseases workgroup mode, supervisors chronicdisease management model; latter includes center (hospital) led station (room) toassist in the perfect center (hospital) and station (room) co-led the completion formula,the center (hospital) organization, station-led perfect (room) and center (hospital)alone perfect.6. Training of grass-roots medical staff in diabetes and their willingness to preventionand control work. Urban and rural primary care doctors agreed that a small number ofexisting professional training, lack of content. Community health service centers ondiabetes prevention and control work ",52.04%of the respondents said the" general"40.14%" very satisfied "or" satisfied "7.82%" not satisfied "or" very dissatisfied ";township hospitals surveyed,54.82%said" general "37.56%" very satisfied "or"satisfied ",7.61%" not satisfied "or" very dissatisfied ".Conclusions1. China’s primary diabetes prevention network system has been basically established,the overall performance of primary health services to prevent and control diabetes.However, human resources, hardware support and financial investment, it shows thecity Diabetes capacity is stronger than in rural areas.2. part of the management is not enough emphasis on the prevention and treatment ofdiabetes, affecting the Diabetes Prevention enhance the ability of primary health services.3. the grass-roots health personnel overall quality is not high, lack of diabetesprevention and management expertise, performance for the prevention andmanagement of diabetes powerless.4. Diabetes knowledge and skills for primary health services and training lag, theimpact of prevention and treatment to enhance the level of medical staff.5. Diabetes no special prevention funding, existing prevention and control work ismainly funded from public health funding, and the amount, support the efforts ofdiabetes prevention and control work.6. primary diabetes management information system is an uneven trend, but the city isbetter than in rural areas.7. poor awareness of the health of residents of diabetes prevention and control workparticipation and cooperation is not strong, diabetes prevention and control work tosolve a problem.Innovation and LimitationsThe study is the first nationwide survey of urban and rural diabetes and otherchronic disease management to carry out the current situation and analysis of diabetesprevention and control capacity of the primary health services, improvementprograms and strategies proposed to further improve China’s grass-roots network ofdiabetes prevention and management system and improve the control capacity. In thisstudy, systems theory, and resource allocation theory of diabetes prevention andcontrol capacity of China’s grass-roots health services from a broad perspective toexplore innovative.Inadequacies and limitations of this study, this study only from the organizationalstructure and resource allocation point of view of diabetes prevention and controlcapacity of the primary health services were analyzed, not collected relevant data toreflect the effectiveness of prevention and treatment in the case of existing resourcesand therefore can not be more precise grasp and improve the ability of primary diabetes for more information. Can further related studies.更多还原