Abstract: Background　The integrated management of diabetic patients has become a very important task for chronic disease management in communities. Shihezi is a county-level municipality of Xinjiang Uyghur Autonomous Region and was the headquarter of the Xinjiang Production and Construction Corp. The aging members of the Corp is making the municipal aging problem incrementally severe，and diabetes and its complications are influencing the well-being of citizens there and aggravating the region's economic burden. However，related researches are rare in this area. Objective　To provide basis for the management of type 2 diabetes mellitus in Shihezi community by investigating the levels of blood glucose，blood pressure，blood lipid and joint control rate of them in patients with type 2 diabetes mellitus （T2DM） in comprehensive management of community service centers and tertiary，level A hospitals from 2014 to 2017. Methods　The author selected 300 eligible T2DM patients from 13 communities under the medical coverage of the First Affiliated Hospital of the Medical College，Shihezi University in November 2014 by cluster sampling method. The 300 patients were given a three-year integrated management treatment and observed for dynamic changes of their blood glucose，blood pressure，blood lipid and other indicators. Results　As of November 2017，there were all together 236 patients finished the follow-up survey. From 2014 to 2017，the comparisons of glycosylated hemoglobin （HbA1c） and fasting plasma glucose （FPG） levels showed that the differences were of no statistical significance （P>0.05）． There were significant differences in systolic blood pressure （SBP） and diastolic blood pressure （DBP） among patients （P<0.05）；SBP in 2015 and 2017 was higher than that in 2014，and DBP in 2017 was lower than that in 2014 （P<0.05）． The levels of total cholesterol （TC），triglyceride （TG），high density lipoprotein cholesterol （HDL-C） and low density lipoprotein cholesterol （LDL-C） in patients were significantly different （P<0.05）；TC and HDL-C levels in 2015 were lower than those in 2014，TC and LDL-C levels in 2016，2017 were lower than those in 2014，HDL-C level in 2016 and 2017 were higher than that in 2015，LDL-C level in 2016 and 2017 were lower than that in 2015，and TG level in 2017 was higher than that in 2016 （P<0.05）． From 2014 to 2017，there was no significant difference in blood glucose control rate both male and female patients （P>0.05）． There were significant differences in blood pressure control rate both male and female patients（P<0.05）；both female and male blood pressure control rates in 2016 were higher than those in 2014 and 2015；and the male blood pressure control rate in 2017 was higher than that in 2014 and the female blood pressure control rate in 2017 was higher than that in 2014 and 2015 （P<0.007）．There was no significant difference in blood lipid control rate in male （P>0.05） while that of female showed that the differences were of statistical significance （P<0.05）；and for female，the control rate in 2015 and 2016 were lower than that in 2014，and that in 2017 was higher than that in 2016 （P<0.007）． There was no significant difference in the joint control rate of blood glucose + blood pressure，blood glucose + blood pressure + blood lipid （P>0.05）；there was significant difference in the joint control rate of blood glucose and blood lipid （P<0.05）；and the joint control rate of blood glucose and blood lipid in 2016 and 2017 was higher than that in 2014 and 2015（P<0.007）.Conclusion　After the integrated management，the blood pressure，blood lipid and control rate of the T2DM in patients living in the 13 communities of Shihezi municipality have made obvious progress and the joint control rates related have also achieved improvements，compared with previous conditions of patients.

Key words: Diabetes mellitus, type 2；Comprehensive management；Blood glucose；Blood pressure；Blood lipid；Community

摘要： 背景　糖尿病患者综合管理已成为社区慢性病管理工作的重要任务，在地处边疆的石河子地区，由于兵团人口构成特点，老龄化更加严重，糖尿病及其并发症严重危害着广大群众的身心健康，也加重了社会和经济负担，且该地区目前缺乏相关性研究。目的　通过调查2014—2017年石河子市社区2型糖尿病（T2DM）患者在三级甲等医院联合社区医院综合管理期间的血糖、血压、血脂水平及其联合达标情况，为石河子市社区T2DM的管理提供有效依据。方法　于2014年11月采用整群抽样法从石河子大学医学院第一附属医院管辖的13个社区抽取符合纳入标准的T2DM患者300例，对患者综合管理3年。观察管理期间患者血糖、血压、血脂各项指标的动态变化。结果　至2017年11月，共236例患者完成随访。2014—2017年，患者糖化血红蛋白（HbA1c）、空腹血糖（FPG）水平比较，差异均无统计学意义（P>0.05）。2014—2017年，患者收缩压（SBP）、舒张压（DBP）比较，差异均有统计学意义（P<0.05）；其中2015年、2017年SBP高于2014年，2017年DBP低于2014年（P<0.05）。2014—2017年，患者总胆固醇（TC）、三酰甘油（TG）、高密度脂蛋白胆固醇（HDL-C）、低密度脂蛋白胆固醇（LDL-C）水平比较，差异均有统计学意义（P<0.05）；其中2015年TC、HDL-C水平低于2014年，2016年、2017年TC、LDL-C水平低于2014年，2016年、2017年HDL-C水平高于2015年，LDL-C水平低于2015年，2017年TG水平高于2016年（P<0.05）。2014—2017年，男性、女性患者血糖达标率比较，差异均无统计学意义（P>0.05）。2014—2017年，男性、女性患者血压达标率比较，差异均有统计学意义（P<0.05）；其中2016年男性、女性血压达标率均高于2014年、2015年，2017年男性血压达标率高于2014年，女性血压达标率高于2014年、2015年（P<0.007）。2014—2017年，男性血脂达标率比较，差异无统计学意义（P>0.05）；2014—2017年，女性血脂达标率比较，差异有统计学意义（P<0.05）；其中2015年、2016年血脂达标率低于2014年，2017年血脂达标率高于2016年（P<0.007）。2014—2017年，患者血糖+血压、血糖+血压+血脂联合达标率比较，差异均无统计学意义（P>0.05）；患者血糖+血脂联合达标率比较，差异有统计学意义（P<0.05）；其中2016年、2017年血糖+血脂联合达标率高于2014年、2015年（P<0.007）。结论　经综合管理后石河子市社区T2DM患者血压、血脂水平及达标率较前明显改善，并且管理后各项指标的联合达标率亦较前提高。

关键词: 糖尿病, 2型；综合管理；血糖；血压；血脂；社区