Prueksaritanond Somjit, Tubtimtes Saisunee, Asavanich Kornthong, Tiewtranon Vasunee
Department of Family Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.
J Med Assoc Thai. 2004 Apr;87(4):345-52.
The prevalence of diabetes mellitus has increased worldwide including Thailand. Management of diabetes should be considered biological and psychosocial. Patient-centered care was applied in the present study. Patient-centered care is a process interaction between the clinician and the patient. It refers to the clinician's behavioral skill in the consultation. Patient-centered care customizes seeking and accepting the patient's ideas, seeking and giving recognition and encouragement, treatment recognition and decision making in response to the individual patient's perspective.
To evaluate the efficacy of patient-centered care on type 2 diabetes mellitus. Their fasting plasma glucose (FPG), hemoglobin A1c (HbA1c), eating and exercise behavior, compliance, symptoms of diabetes as well as satisfaction were compared before and after the intervention.
The quasi-experimental design (controlled before and after intervention) was conducted among 78 patients with type 2 diabetes mellitus who regularly attended the outpatient clinic, Family Medicine Department, whose FPG was more than 150 mg/dL, non pregnant, could communicate well in Thai and had no other complications. The patients were required to follow on Wednesday morning every 6-10 weeks for one year. A group of 6-10 patients was appointed in each visit. The six interconnecting components of patient-centered care were applied. (1) The patients and the researchers were introduced to each other to enhance the relationship between the patients, doctors and researchers. (2) In each visit, by using a group process and individual approach, the authors explored, assessed and analyzed both the disease, the illness (patient's ideas, feelings, expectations and functions), drug compliance, eating and exercise behavior. (3) The patient's life, family history, psychological and social behaviors were emphasized. (4) Setting the goals of FPG level that is achievable and agreeable to both the physician and patients. (5) Each patient was required to attend both nutrition and exercise education workshops. (6) Self care and self records on food items as well as nutrition and exercise practice were emphasized in order to incorporate them into their lifestyle.
There were 53 females (67.9%) and 25 males (32.1%). Average age was 57.2 years. Diabetes duration was 6.75 +/- 5.45 years. Mean FPG of overall subjects decreased 43.07 +/- 76.32 mg/dL. About 16.44% had FPG below 126 mg/dL. 55.13% retained the same hypoglycemic medications, 10.5% had decreased dosage. Amongst 33 subjects (42.3%) who completed the program, FPG decreased 73.58 +/- 70.99 mg/dL (p < 0. 000). HbA1c decreased 0. 92 +/- 1.41% (p = 0. 001). Eating behavior (p < 0.000) and exercise behavior (p < 0.05) were better. Symptoms of diabetes were improved. Patient's satisfaction indicated that they had a better understanding of the disease and illness. They were eager to share their experiences with others and able to develop a relationship with the health care team. Amongst 45 patients (57.7%) who partially followed the program, FPG decreased 39.55 +/- 68.54 mg/dL (p = 0. 001).
Glycemic control of type 2 diabetes subjects was improved by patient-centered care. Eating and exercise behaviors, compliance, symptoms of diabetes were better. This pilot study showed that the health status was improved not only by the biological indicators but also by behavior. The present study provided a beneficial impact on improving the health status of type 2 diabetes.
包括泰国在内，全球糖尿病患病率均有所上升。糖尿病管理应兼顾生物因素和心理社会因素。本研究采用以患者为中心的护理模式。以患者为中心的护理是临床医生与患者之间的一种互动过程。它指的是临床医生在诊疗过程中的行为技巧。以患者为中心的护理需要根据患者的想法进行定制化护理，寻求并认可患者的想法，给予认可和鼓励，根据患者个体情况进行治疗决策。
评估以患者为中心的护理对2型糖尿病的疗效。比较干预前后患者的空腹血糖（FPG）、糖化血红蛋白（HbA1c）、饮食和运动行为、依从性、糖尿病症状以及满意度。
采用准实验设计（干预前后对照），对78例2型糖尿病患者进行研究，这些患者定期到家庭医学科门诊就诊，FPG高于150mg/dL，非妊娠，泰语沟通良好且无其他并发症。患者需每6 - 10周在周三上午随访，为期一年。每次就诊安排6 - 10名患者。应用以患者为中心护理的六个相互关联的组成部分。（1）患者与研究人员相互介绍，以增强患者、医生和研究人员之间的关系。（2）每次就诊时，通过小组讨论和个体访谈的方式，研究人员探究、评估和分析疾病、病情（患者的想法、感受、期望和功能）、药物依从性、饮食和运动行为。（3）强调患者的生活、家族史、心理和社会行为。（4）设定医生和患者都认可且可实现的FPG目标水平。（5）要求每位患者参加营养和运动教育工作坊。（6）强调自我护理以及记录食物摄入情况、营养和运动实践，以便将其融入生活方式。
共有53名女性（67.9%）和25名男性（32.1%）。平均年龄为57.2岁。糖尿病病程为6.75±5.45年。所有受试者平均FPG下降43.07±76.32mg/dL。约16.44%的患者FPG低于126mg/dL。55.13%的患者维持相同的降糖药物治疗，10.5%的患者药物剂量减少。在33名（42.3%）完成该项目的受试者中，FPG下降73.58±70.99mg/dL（p<0.000）。HbA1c下降0.92±1.41%（p = 0.001）。饮食行为（p<0.000）和运动行为（p<0.05）有所改善。糖尿病症状得到改善。患者满意度表明他们对疾病有了更好的理解。他们渴望与他人分享自己的经历，并能够与医疗团队建立良好关系。在45名（57.7%）部分参与该项目的患者中，FPG下降39.55±68.54mg/dL（p = 0.001）。
以患者为中心的护理改善了2型糖尿病患者的血糖控制。饮食和运动行为、依从性、糖尿病症状均有所改善。这项初步研究表明，健康状况的改善不仅体现在生物指标上，还体现在行为方面。本研究对改善2型糖尿病患者健康状况产生了有益影响。
