【摘要】：目的探討2型糖尿病(T2DM)管理八年聯(lián)合達(dá)標(biāo)對心血管事件及全因死亡的影響。方法在北京社區(qū)糖尿病研究(BCDS)課題內(nèi),以勁松社區(qū)441例T2DM患者為研究對象,患者入選時(shí)間為2008年8—12月,隨訪至2016年9月,無脫落病例。采用隨機(jī)數(shù)字表法,將納入患者分為強(qiáng)化管理組(n=220)和標(biāo)準(zhǔn)管理組(n=221)。兩組患者均由全科醫(yī)師在三級甲等醫(yī)院專家指導(dǎo)下進(jìn)行"一對一"管理,定期隨訪及監(jiān)測各項(xiàng)指標(biāo),及早發(fā)現(xiàn)并發(fā)癥并進(jìn)行干預(yù)。兩組患者的管理差異主要為隨訪周期及重要指標(biāo)的檢測頻率不同:強(qiáng)化管理組患者每2個(gè)月隨訪1次,糖化血紅蛋白(Hb A1c)每3個(gè)月檢測1次、尿微量清蛋白排泄率(UAER)每6個(gè)月檢測1次;標(biāo)準(zhǔn)管理組患者每3個(gè)月隨訪1次,Hb A1c每6個(gè)月檢測1次、UAER每年檢測1次。比較兩組患者2008—2016年各代謝指標(biāo)達(dá)標(biāo)率及聯(lián)合達(dá)標(biāo)率、終點(diǎn)事件發(fā)生率,分析聯(lián)合達(dá)標(biāo)次數(shù)對心血管事件及全因死亡的影響。結(jié)果強(qiáng)化管理組患者2012年空腹血糖(FPG)達(dá)標(biāo)率低于標(biāo)準(zhǔn)管理組,2015—2016年FPG、Hb A1c、低密度脂蛋白膽固醇(LDL-C)達(dá)標(biāo)率及聯(lián)合達(dá)標(biāo)率高于標(biāo)準(zhǔn)管理組,2015年血壓達(dá)標(biāo)率高于標(biāo)準(zhǔn)管理組,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。兩組患者2008—2016年全因死亡、腦血管事件、心血管事件、糖尿病腎病、糖尿病視網(wǎng)膜病變、周圍血管事件、腫瘤發(fā)生率及總終點(diǎn)事件發(fā)生率比較,差異無統(tǒng)計(jì)學(xué)意義(P0.05)。共139例(31.5%)患者聯(lián)合達(dá)標(biāo)次數(shù)≥3次,余302例(68.5%)聯(lián)合達(dá)標(biāo)次數(shù)3次。聯(lián)合達(dá)標(biāo)次數(shù)≥3次患者全因死亡、心血管事件發(fā)生率及總終點(diǎn)事件發(fā)生率低于聯(lián)合達(dá)標(biāo)次數(shù)3次患者,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。經(jīng)Log-rank檢驗(yàn),聯(lián)合達(dá)標(biāo)次數(shù)≥3次患者全因死亡、心血管事件累積風(fēng)險(xiǎn)低于聯(lián)合達(dá)標(biāo)次數(shù)3次患者,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。管理第6年,聯(lián)合達(dá)標(biāo)次數(shù)≥3次患者的全因死亡、心血管事件發(fā)生率低于聯(lián)合達(dá)標(biāo)次數(shù)3次患者,差異有統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論社區(qū)醫(yī)院與三級甲等醫(yī)院聯(lián)合精細(xì)管理可有效提高T2DM患者的聯(lián)合達(dá)標(biāo)率,聯(lián)合達(dá)標(biāo)次數(shù)≥3次患者的全因死亡和心血管事件發(fā)生率在管理第6年明顯降低。
[Abstract]:Objective to investigate the effects of 8-year management of type 2 diabetes mellitus (T2DM) on cardiovascular events and all-cause death. Methods A total of 441 T2DM patients from Jinsong community were selected as subjects in the (BCDS) study of Beijing community diabetes mellitus. The patients were followed up from August to December of 2008 and followed up to September 2016. There were no shedding cases. The patients were divided into two groups: intensive management group (n = 220) and standard management group (n = 221). The patients in both groups were managed by general practitioners under the guidance of experts in Grade 3A Hospital, followed up and monitored regularly, complications were detected as soon as possible and intervention was carried out. The difference in management between the two groups was mainly in the follow-up period and the frequency of detection of important indicators: the patients in the intensive management group were followed up every 2 months, and the Hb A1c was detected every 3 months. Urinary albumin excretion rate (UAER) was detected every 6 months. The patients in the standard management group were followed up every 3 months, Hb A1c was tested every 6 months, and UAER was detected once a year. The rate of reaching the standard and the rate of combined reaching the standard and the incidence of the end-point events were compared between the two groups from 2008 to 2016. The effects of the times of the combination reaching the standard on cardiovascular events and all-cause death were analyzed. Results in the intensive management group, the level of fasting blood glucose (FPG) in 2012 was lower than that in the standard management group. In 2015-2016, FPG,Hb A1c, low density lipoprotein cholesterol (LDL-C) and combined rate were higher than those in the standard management group. The blood pressure reached the standard rate in 2015 was higher than the standard management group, the difference was statistically significant (P0.05). All-cause deaths, cerebrovascular events, cardiovascular events, diabetic nephropathy, diabetic retinopathy, peripheral vascular events, tumor incidence and total endpoint events were compared between the two groups from 2008 to 2016. There was no significant difference (P0.05). 139 patients (31.5%) achieved the standard more than 3 times, the remaining 302 patients (68.5%) achieved the standard more than 3 times. The incidence of cardiovascular events and total end-point events were significantly lower than those of the patients who achieved the goals more than 3 times. The difference was statistically significant (P0.05). The results of Log-rank test showed that all the patients died and the cumulative risk of cardiovascular events was lower than that of the patients who achieved the standard more than 3 times. The difference was statistically significant (P0.05). In the sixth year of management, the incidence of cardiovascular events was lower than that of the patients who achieved the standard more than 3 times, the difference was statistically significant (P0.05). Conclusion the combined fine management of community hospital and Grade 3A hospital can effectively improve the rate of T2DM patients meeting the standard, and the incidence of all-cause death and cardiovascular events in patients with total death and cardiovascular events decreased significantly in the sixth year of management.
【作者單位】： 北京市朝陽區(qū)勁松社區(qū)衛(wèi)生服務(wù)中心;首都醫(yī)科大學(xué)附屬北京地壇醫(yī)院病案統(tǒng)計(jì)室;北京軍區(qū)總醫(yī)院內(nèi)分泌科;首都醫(yī)科大學(xué)附屬北京同仁醫(yī)院內(nèi)分泌科;
【基金】：首都衛(wèi)生發(fā)展科研專項(xiàng)(2016-1-2057;2016-2-2054) 首都臨床特色應(yīng)用研究項(xiàng)目(Z151100004015021) 國際糖尿病聯(lián)盟IDF-BRIDGES 4th Round of Funding(ST12-024)
【分類號】：R587.1

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