北京协和医院糖尿病强化治疗门诊综合管理现状分析

Analysis of the current situation of comprehensive management at intensive diabetes treatment clinic in Peking Union Medical College Hospital

目的评估北京协和医院糖尿病强化治疗门诊患者血糖、血压、血脂及3项综合指标经规律随访12个月后达标情况并分析影响因素,探索糖尿病强化治疗门诊综合管理模式。方法该研究为前瞻性、观察性队列研究,选取2012年至2023年在北京协和医院糖尿病强化治疗门诊长期规律随诊的糖尿病患者为研究对象,连续随诊12个月以上,收集患者在第1次就诊和随访第3、6、9和12个月的临床资料,评估以糖化血红蛋白<7%、血压<130/80 mmHg(1 mmHg=0.133 kPa)、低密度脂蛋白胆固醇<2.6 mmol/L作为控制目标时,患者血糖、血压、血脂及3项综合指标的达标率,并分析性别、年龄、糖尿病类型、病程、体重指数、合并症、并发症、治疗方案等因素对糖尿病综合管理结局的影响。结果共纳入232例患者,2型糖尿病210例(90.5%),1型糖尿病13例(5.6%),成人隐匿性自身免疫性糖尿病5例(2.2%),全胰腺切除术后继发糖尿病3例(1.3%)及线粒体糖尿病1例(0.4%)。经过3个月的强化管理,血糖(67.7%比34.1%,Kappa=0.336,P<0.001)、血压(53.4%比37.5%,Kappa=0.159,P=0.001)、血脂(59.1%比39.2%,Kappa=0.198,P<0.001)、3项综合指标(20.7%比3.0%,Kappa=0.177,P<0.001)的达标率均显著升高,继续治疗6、9、12个月后,血糖、血压、血脂及综合指标达标率均稳定而持续增加。Logistic回归分析显示,基线高血糖(P=0.002)、病程≥5年(P<0.001)、吸烟(P=0.009)、饮酒(P=0.038)、有糖尿病并发症(P=0.001)、应用口服降糖药物联合胰岛素的降糖方案(P<0.001)、应用抗血小板药物(P=0.037)是糖化血红蛋白控制不达标的危险因素。基线高血压(P<0.001)、饮酒(P=0.030)、合并血脂异常(P=0.028)是血压控制不达标的危险因素。基线低密度脂蛋白胆固醇不达标(P=0.020)、未应用他汀类药物(P<0.001)是血脂控制不达标的危险因素。结论在北京协和医院糖尿病强化治疗门诊长期随诊患者中,血糖、血脂、血压达标率及综合达标率较高,但仍需尽可能提高患者的依从性,重视体重管理,坚持糖尿病的综合治疗。

Objective To assess the goal fulfillment in terms of blood glucose,blood pressure,blood lipid,and the composite indicator of these three in patients with diabetes who received intensified treatment at Peking Union Medical College Hospital and regular follow-up for 12 months,analyze the influencing factors,and explore the comprehensive management model for intensive diabetes treatment outpatient services.Methods This study was a prospective,observational cohort study.The diabetes patients who received long-term regular follow-up at the intensive diabetes treatment outpatient clinic of Peking Union Medical College Hospital from 2012 to 2023 were selected as the research subjects.They were followed up and clinical data were collected at the 1st,3rd,6th,9th,and 12th months of follow-up.The study assessed the goal fulfillment rates in terms of blood glucose,blood pressure,blood lipid,and the composite indicator of these three,with the goals of glycated hemoglobin(HbA1c)<7%,blood pressure<130/80 mmHg,and low-density lipoprotein cholesterol(LDL-C)<2.6 mmol/L.The study also analyzed the impact of factors,including gender,age,type of diabetes,duration of diabetes,body mass index,comorbidities,complications,and treatment regimens,on the outcomes of comprehensive diabetes management.Results A total of 232 patients were included in the study,of whom 210 were with type 2 diabetes(90.5%),13 with type 1 diabetes(5.6%),5 with latent autoimmune diabetes of the adult(2.2%),3 with diabetes after total pancreatectomy(1.3%),and 1 with mitochondrial diabetes(0.4%).After 3 months of intensified management,the goal fulfillment rates of blood glucose(67.7%vs.34.1%,Kappa=0.336,P<0.001),blood pressure(53.4%vs.37.5%,Kappa=0.159,P=0.001),blood lipid(59.1%vs.39.2%,Kappa=0.198,P<0.001),and the composite indicator(20.7%vs.3.0%,Kappa=0.177,P<0.001)were significantly increased.Continued treatment at 6,9,and 12 months showed stable and sustained increases in the goal fulfillment rates of blood glucose,blood pressure,blood lipid,and the composite indicator.Logistic regression analysis showed that baseline hyperglycemia(P=0.002),disease duration≥5 years(P<0.001),smoking(P=0.009),alcohol consumption(P=0.038),presence of diabetic complications(P=0.001),combination therapy with oral antidiabetic drugs and insulin(P<0.001),and use of antiplatelet drugs(P=0.037)were risk factors for uncontrolled HbA1c.Baseline hypertension(P<0.001),alcohol consumption(P=0.030),and comorbid dyslipidemia(P=0.028)were risk factors for uncontrolled blood pressure.Baseline uncontrolled LDL-C(P=0.020)and non-use of statins(P<0.001)were risk factors for uncontrolled blood lipid.Conclusions Among patients with the long-term follow-up at our intensive diabetes treatment clinic,the goal fulfillment rates of blood glucose,blood lipid,blood pressure,and the composite indicator of these three are relatively higher.However,it is still necessary to improve patient compliance as much as possible,emphasize weight management,and persist on the comprehensive diabetes treatment.