DPCC模式下专科与社康联动管理2型糖尿病的效果  

Effect of joint management of type 2 diabetes mellitus between specialty department and community health under National Diabetes Prevention and Control Center(DPCC)model

作　　者：黄莺 钱毅 伍旭炽 周钟玉 王聪 王琳 黄彩艳 陈壮森 张艳荣 王闪闪 王露 万杰 杨瑞红 王惠雅 陈燕 何程 冯琨 阎德文[2] Huang Ying;Qian Yi;Wu Xuchi;Zhou Zhongyu;Wang Cong;Wang Lin;Huang Caiyan;Chen Zhuangsen;Zhang Yanrong;Wang Shanshan;Wang Lu;Wan Jie;Yang Ruihong;Wang Huiya;Chen Yan;He Cheng;Feng Kun;Yan Dewen(Department of Endocrinology,Pingshan District People′s Hospital of Shenzhen,Shenzhen 518100,China;Department of Endocrinology,Shenzhen Second People′s Hospital,Shenzhen Center for Diabetes Control and Prevention,Shenzhen Clinical Research Center for Metabolic Diseases,Shenzhen 518100,China)

机构地区：[1]深圳市坪山区人民医院内分泌科,深圳518100 [2]深圳市第二人民医院内分泌科,深圳市糖尿病防治中心,深圳市代谢性疾病临床研究中心,深圳518100

出　　处：《中国医师杂志》2025年第3期338-342,共5页Journal of Chinese Physician

基　　金：广东省教育厅自然科学项目(2024KTSCX074);深圳市卫生健康委员会医防融合项目(深卫健体改-2019-25);深圳市坪山区卫生健康系统科研项目(202248,2024322)。

摘　　要：目的分析国家糖尿病标准化防控中心(DPCC)模式下专科与社康联动管理2型糖尿病(T2DM)的效果。方法回顾性纳入2022年1月1日—2024年12月31日DPCC深圳坪山中心管理的2527例T2DM患者,分析2022年度(n=564)、2023年度(n=1477)、2024年度(n=2527)糖尿病患者管理后的下转率、复查率、血压达标率、代谢指标(腰围、体重指数、空腹血糖、糖化血红蛋白、血脂)达标率以及糖尿病慢性并发症(动脉粥样硬化性心血管疾病、微血管疾病、糖尿病周围神经病变)筛查率。结果2022年度、2023年度、2024年度的下转率逐年提高(22.8%vs 67.2%vs 89.9%,P<0.01),复查率(41.1%vs 62.2%vs 52.7%,P<0.01)、并发症筛查率(51.6%vs 85.3%vs 62.2%,P<0.01)、血压达标率(53.1%vs 78.0%vs 67.2%,P<0.01)、体重指数达标率(13.2%vs 17.3%vs 28.6%,P<0.01)、空腹血糖达标率(46.4%vs 60.2%vs 68.5%,P<0.01)、糖化血红蛋白达标率(58.4%vs 63.2%vs 45.6%,P<0.01)相对提升,腰围达标率(30.6%vs 27.7%vs 21.6%)、血脂达标率(33.6%vs 35.5%vs 31.9%)无明显提升,其中2024年度的复查率、血压达标率、并发症筛查率低于2023年度,高于2022年度。结论DPCC模式下专科与社康联动管理2型糖尿病,对提高糖尿病患者的下转率、复查率、血压达标率、代谢指标达标率以及糖尿病相关慢性并发症筛查率有明显作用。同时也发现随着分级诊疗的进行却出现患者的复查率、并发症筛查率以及血压、腰围、血脂、糖化血红蛋白的达标率较前下降的情况,需进一步分析原因并完善解决。ObjectiveTo analyze the effect of joint management of type 2 diabetes mellitus(T2DM)between specialty and community under the model of National Diabetes Prevention and Control Center(DPCC).MethodsA total of 2527 T2DM patients managed by DPCC Pingshan Center of Shenzhen from January 1,2022 to December 31,2024 were retrospectively included.After management,the rate of downturn,reexamination rate,blood pressure compliance rate,metabolic indicators(waist circumference,body mass index,fasting blood glucose,glycosylated hemoglobin,blood lipids)and screening rate of chronic complications of diabetes(atherosclerotic cardiovascular disease,microvascular disease,diabetic peripheral neuropathy)were analyzed.Those included 2022(n=564),2023(n=1477),and 2024(n=2527).ResultsThe downturn rate in 2022,2023 and 2024 increased year by year(22.8%vs 67.2%vs 89.9%,P<0.01),and the review rate(41.1%vs 62.2%vs 52.7%,P<0.01),complication screening rate(51.6%vs 85.3%vs 62.2%,P<0.01),blood pressure compliance rate(53.1%vs 78.0%vs 67.2%,P<0.01),body mass index compliance rate(13.2%vs 17.3%vs 28.6%,P<0.01),fasting blood glucose meeting rate(46.4%vs 60.2%vs 68.5%,P<0.01),glycated hemoglobin meeting rate(58.4%vs 63.2%vs 45.6%,P<0.01)were relatively improved.Waist circumference compliance rate(30.6%vs 27.7%vs 21.6%)and blood lipid compliance rate(33.6%vs 35.5%vs 31.9%)were not significantly improved,and the review rate,blood pressure compliance rate and complication screening rate in 2024 were lower than those in 2023 and higher than those in 2022.ConclusionsThe combined management of type 2 diabetes under the DPCC model has significant effects on improving the down-conversion rate,rediagnosis rate,blood pressure compliance rate,metabolic index compliance rate and the screening rate of diabetes-related chronic complications in patients with diabetes.At the same time,it was also found that with the progress of hierarchical diagnosis and treatment,the review rate,complication screening rate,blood pressure,waist circumference,blood lipid and glycos

关 键 词：糖尿病 2型 预防 控制 社区卫生 

分 类 号：R587.1[医药卫生—内分泌]