中文摘要：

目的探讨全科医师团队在糖尿病患者健康管理中的应用效果。方法随机选取2012年10月-2013年11月深圳市宝安区西乡街道管理的4家社区作为实验组,其1219名糖尿病患者采用全科医师团队进行健康管理;同时选取社区类型、人口构成、经济水平等相一致的5家社区作为对照组,其1283名糖尿病患者延续以前的健康管理模式。比较两组的效果。结果两组干预后的血糖控制率、规律服药率、血糖自我监测率显著高于干预前,差异有统计学意义（P〈0.05）。实验组干预后的血糖控制率、规律服药率、血糖自我监测率显著高于对照组,差异有统计学意义（P〈0.05）。实验组的危险行为改变率为33.0%,显著高于对照组的25.0%,差异有统计学意义（P〈0.05）。结论全科医师团队模式是新型且高效的社区健康服务模式,将会成为全科医学发展的重要方向。

英文摘要：

Objective To explore the application effect of general practitioners team model in health management of patient with diabetes in community. Methods 4 community health service centers of Xixiang street management of Baoan district in Shenzhen city from October 2012 to November 2013 was randomly selected as the experimental group,and 1219 diabetic patients were given general practitioners team model.5 community from other health service centers,which had the same community type,population distribution and economic standard with the community in study group were selected as the control group,and 1283 diabetic patients were given first diagnosis responsibility model.The effect in two groups was compared. Results The rate of glucose control,regular medication,glucose self-monitoring in two groups after intervention was higher than that before intervention,with significant difference（P〈0.05）.The rate of glucose control,regular medication,glucose self-monitoring in the experimental group after intervention was higher than that in the control group,with significant difference（P〈0.05）.The rate of risk behavior change in the experimental group after intervention was 33.0%,which was higher than 25.0% in the control group,with significant difference（P〈0.05）. Conclusion General practitioners team model is a new and efficient community health service model,and it will be an important development direction of general family medicine.