背景快乐生活俱乐部TM慢性病管理项目的 目的,是通过帮助患者改变行为生活方式,改善患者对医疗服务的依从性和自我管理能力,有效地利用医疗服务,改善生活质量.糖尿病的共病现象增加了患者对医疗卫生服务的利用和成本,对共病的管理将有利于提高社区慢性病管理的效率.本文的目的 是通过快乐生活俱乐部TM试点的数据分析,探讨2型糖尿病的共病及其对社区干预计划和实施的意义.方法 在试点社区招募100名55岁及以上的2型糖尿病患者,随机分配成干预组和对照组.10名经过澳大利亚健康心理学培训的社区医生和护士,对干预组患者提供以动机谈话为主的健康教练服务.研究者在干预前、干预6个月和12个月对患者进行问卷调查、心理健康状况筛查和临床检查监测,掌握患者的躯体和心理共病状况.采用SPSS 18.0对数据进行统计分析.结果 77%的糖尿病患者同时患心血管疾病,37%的糖尿病患者患骨关节疾病.凯斯勒心理忧郁量表筛查结果,32%的患者评分大于22.48%的糖尿病患者患1种共病,31%的患者患2种共病,7%的患者患3种共病.干预组患者在干预后收缩压有下降趋势,但统计学检验结果差异无显著性.结论 心血管疾病是糖尿病患者最普遍存在的共病,其次为骨关节病.糖尿病患者心理忧郁的可能性较高.糖尿病与心血管疾病之间存在共同的行为危险因素.对膳食和身体锻炼的行为干预,将有利于对慢性病的综合管理,提高社区慢性病管理的效率.%Background Comorbidity of diabetes increased use and cost of medical service. Most of comorbidity shared same modifiable risk factors with diabetes mellitus. Purpose of this report is to explore comorbidities based on the Happy Life Club pilot questionnaire data and discuss effective approach of managing diabetes and comorbidities. Methods 100 patients with diabetes aged 55 year and above were recruited anD randomly allocateD into intervention and routine treatment control groups. Ten community doctors and nurses were trained in motivational interviewing ( MI ) by Australian health psychologists, and applied the skill in the treatment of the participants of the MI group. Both groups also received routine diabetes management recoMmended in China national diabetes guideline. Questionnaire and clinical measure data were collected at baseline, 6th month and 12th months following intervention. Type and duration of comorbidities/conditions of diabetes patients were found in the monitors. Descriptive analvsis and statistic test was performed using SPSS 18.0. Results 77％ of diabetic patient had cardiovascular conditions. 37％ of participants had arthritis or other joint/bone condition. 32％ of participants had K10 score higher than 22 ( high or very high distress ) . Among participants, 48％ of them had another condition; 31％ of them had two co - conditions, and 7％ of them had three comorbidities. Decrease of systolic blood pressure in MI group was evident. however, no statistically significant. Conclusion Cardiovascular conditions are the most common comorbidity among diabetes patients, followed by arthritis, Distress is also common among participants. CVD and diabetes share common modifiable risk behaviours such as poor diets and physical inactive. MI intervention that target on the shared behaviours will increase cost - effectiveness of community - based chronic disease management.
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