背景 糖尿病患者人數不斷增長，給社區糖尿病管理帶來巨大壓力，在中國全科醫師常常身兼數職，以致糖尿病管理不佳，然而國際上已證實社區護理人員在慢性病管理中的的角色功能十分有效，因此，在中國推動護理人員主導的社區糖尿病管理模式，並且評價其成效日益重要。

目的 探討社區護理人員引領的團隊管理對糖尿病患者的疾病改善效果。

方法 方 法採用試驗性研究設計，選取成都市武侯區2家社區衛生服務機構分別為試驗組和對照組，並於所 在社區納入2型糖尿病患者作為研究對象。試驗組患者接受社區護理人員引領的團隊管理服務2 年；對照組維持現有的管理服務。分別在介入前、介入後半年、1年及2年評價患者的糖化血色素 （HbA1c）、身體質量指數、腰圍、視力、踝肱指數、腎病指數、尿蛋白及心電圖。

結果 兩社區共納入研究對象179例，其中試驗組88例，對照組91例。通過介入，試驗組患者糖化血色素、 踝肱指數、腰圍較對照組明顯改善（F = 28.894，p < .01；F = 4.065，p < .01；F = 5.540，p < .01）；身體質 量指數、視力、腎病指數、尿蛋白及心電圖與對照組差異無統計學意義，但維持了上述指標的穩定。

結論 社區護理人員引領的團隊管理，可以改善患者的血糖控制，改善或維持併發症相關指標，在一定程度上起到了預防相關併發症的作用。

Background: Managing increasing numbers of diabetic patients is placing increasing pressure on healthcare providers, especially general practitioners, who usually serve in multiple roles. This situation has caused generally poor results in terms of diabetes management. However, community nurses in some countries have successfully and effectively controlled chronic diseases among their patients. Therefore, the effects of nurse-led management is worth further exploration in order to better understand and promote this mode of care. Purpose: To explore the effects of community-nurse-led team management on diabetes patients. Methods: An experimental research design was adopted. Patients with type 2 diabetes were recruited from two community health centers (the first for the intervention group, the second for the control group) in Wuhou District, Chengdu City, China. The intervention group received nurse-led team management care for 2 years, while the control group received standard care. The evaluations were conducted before the intervention and at 6, 12, and 24 months into the intervention. Outcomes included glycosylated hemoglobin (HbA1c) level, body mass index, waist circumference, visual acuity, ankle brachial index, kidney function index, urinary protein level, and electrocardiogram. Results: The 179 participants included 88 in the intervention group and 91 in the control group. After the intervention, HbA1c level, ankle brachial index, and waist circumference were all significantly better in the intervention group than in the control group (F = 28.894, p < .01; F = 4.065, p < .01; F = 5.540, p < .01). The other outcome variables remained statistically similar between both groups throughout the study period. Conclusion: Community nurse-led team management is an effective mode of care in terms of controlling blood glucose control and preventing diabetes-related complications.