互联网+共同照护模式下复诊频率对糖尿病患者自我管理能力及糖化血红蛋白的影响

Effect of follow-up frequency on self-management ability and glycated hemoglobin A1c in patients with diabetes mellitus in internet plus shared care mode

目的探讨不同复诊频率对在互联网+共同照护门诊就诊超过2年的2型糖尿病患者自我管理能力及代谢指标的影响。方法选择所有于2018年第一季度、第四季度及2019年第四季度均在北京大学第一医院糖尿病共同照护门诊完成季度或年度复诊的2型糖尿病患者496例进行回顾性研究。按2018年1月至12月期间实际复诊次数将受试者分为随访≥4次组(330例)、随访3次组(128例)和随访≤2次组(38例)。采用《糖尿病自我管理行为量表6》(SDSCA-6)评价糖尿病患者自我管理行为。以年龄、性别、糖尿病病程、基线代谢指标[体质指数(BMI)、糖化血红蛋白(HbA1c)、低密度脂蛋白胆固醇(LDL-C)、收缩压、舒张压]、基线胰岛素使用情况、基线自我管理能力评分为协变量用R 3.4.4及TWANG程序包进行三组倾向性评分加权法分析,采用方差分析或非参数检验比较各组随访1年时各项自我管理能力评分的人群平均治疗效果(ATE)及各组随访1年及2年末代谢指标的ATE差异。结果经三组倾向性评分加权法分析,与随访≤2次组相比,随访≥4次组1年末随访时运动(+1.16分,P<0.01)、自我监测血糖(+0.82分,P=0.04)及足部检查(+0.99分,P<0.05)评分方面显著改善,随访3次组1年末随访时在运动(+1.50分,P<0.01)及自我监测血糖(+1.10分,P=0.02)评分方面显著改善;随访≥4次组在1年随访时HbA1c有降低趋势(与随访3次组相比-0.25%,P=0.05;与随访≤2次组相比-0.34%,P=0.06);而在2年随访时随访≥4次组HbA1c降低有统计学意义(与随访3次组相比-0.34%,P=0.01;与随访≤2次组相比-0.55%,P<0.01)。各组间随访1年末在其他自我管理能力的差异及随访1年或2年末BMI、LDL-C或其他代谢指标的差异均无统计学意义(均P>0.05)。结论在北京大学第一医院互联网+糖尿病共同照护门诊背景下规律随访的2型糖尿病患者,维持每年3~4次复诊频率可显著改善其运动及自我监测血糖的自我管理能力;维持每年4次复诊频率可显著改善其足部检查的自我管理能力水平,并可持续显著改善血糖控制状况。

Objective To explore the effect of of follow-up frequency on self-management ability and metabolic profiles in patient with type 2 diabetes mellitus who have been visiting Internet plus Shared Care clinic for more than 2 years. Methods A retrospective study was conducted in 496 patients with type 2 diabetes who completed quarterly or annual follow-up visit in the diabetes shared care clinic of Peking University First Hospital in the first quarter, the fourth quarter of 2018 and the fourth quarter of 2019. According to the actual number of follow-up visits from January to December in 2018, the subjects were divided into follow-up≥4 times group (n=330), 3 times follow-up group (n=128), and follow-up≤2 times group (n=38). SDSCA-6 was used to evaluate self-management behavior of patients. Age, gender, disease duration of diabetes, baseline metabolic indexes [body mass index, HbA1c, low-density lipoprotein-cholesterol (LDL-C), systolic blood pressure, diastolic blood pressure], baseline insulin use and baseline self-management ability score were used as covariates to analyze three groups′ propensity score weighting by using R3.4.4 and TWANG package. The differences in the scores of self-management ability (average treatment effect in the population, ATE) at 1-year follow-up and the difference in metabolic profiles (ATE) at 1-year and 2-year follow-up in each group were compared by ANOVA or nonparametric test.Results Compared with follow-up≤2 times group, the scores of exercise (+1.16 points, P<0.01), self-monitoring blood glucose (+0.82 points, P=0.04) and foot examination (+0.99 points, P<0.05) in follow-up≥4 times group at 1-year were significantly improved. The scores of exercise (+1.50 points, P<0.01) and self-monitoring blood glucose (+1.10 points, P=0.02) in 3 times follow-up group at 1-year were significantly improved. HbA1c showed improved trend in follow-up≥4 times group at 1-year follow-up (compared with 3 times follow-up group -0.25%, P=0.05;compared with follow-up≤2 times group -0.34%, P=0.06), but was significantly improved in follow-up≥4 times group at 2-year follow-up (compared with 3 times follow-up group -0.34%, P=0.01;compared with follow-up≤2 times group -0.55%, P<0.01). There was no significant difference in other self-management ability at 1-year nor body mass index, LDL-C or other metabolic indexes at 1-year or 2-year follow-up (P>0.05).Conclusion In patients with type 2 diabetes mellitus who follow up regularly in the Internet plus Diabetes Shared Care clinic, the frequency of 3-4 visits per year can significantly improve their self-management ability on exercise and self-monitoring blood glucose. The frequency of 4 visits per year can significantly improve the self-management ability on foot examination and significantly improve blood glucose control status continually.