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目的探讨2型糖尿病(T2DM)管理八年联合达标对心血管事件及全因死亡的影响。方法在北京社区糖尿病研究(BCDS)课题内,以劲松社区441例T2DM患者为研究对象,患者入选时间为2008年8—12月,随访至2016年9月,无脱落病例。采用随机数字表法,将纳入患者分为强化管理组(n=220)和标准管理组(n=221)。两组患者均由全科医师在三级甲等医院专家指导下进行“一对一”管理,定期随访及监测各项指标,及早发现并发症并进行干预。两组患者的管理差异主要为随访周期及重要指标的检测频率不同:强化管理组患者每2个月随访1次,糖化血红蛋白(Hb A1c)每3个月检测1次、尿微量清蛋白排泄率(UAER)每6个月检测1次;标准管理组患者每3个月随访1次,Hb A1c每6个月检测1次、UAER每年检测1次。比较两组患者2008—2016年各代谢指标达标率及联合达标率、终点事件发生率,分析联合达标次数对心血管事件及全因死亡的影响。结果强化管理组患者2012年空腹血糖(FPG)达标率低于标准管理组,2015—2016年FPG、Hb A1c、低密度脂蛋白胆固醇(LDL-C)达标率及联合达标率高于标准管理组,2015年血压达标率高于标准管理组,差异有统计学意义(P<0.05)。两组患者2008—2016年全因死亡、脑血管事件、心血管事件、糖尿病肾病、糖尿病视网膜病变、周围血管事件、肿瘤发生率及总终点事件发生率比较,差异无统计学意义(P>0.05)。共139例(31.5%)患者联合达标次数≥3次,余302例(68.5%)联合达标次数<3次。联合达标次数≥3次患者全因死亡、心血管事件发生率及总终点事件发生率低于联合达标次数<3次患者,差异有统计学意义(P<0.05)。经Log-rank检验,联合达标次数≥3次患者全因死亡、心血管事件累积风险低于联合达标次数<3次患者,差异有统计学意义(P<0.05)。管理第6年,联合达标次数≥3次患者的全因死亡、心血管事件发生率低于联合达标次数<3次患者,差异有统计学意义(P<0.05)。结论社区医院与三级甲等医院联合精细管理可有效提高T2DM患者的联合达标率,联合达标次数≥3次患者的全因死亡和心血管事件发生率在管理第6年明显降低。
Objective To investigate the effect of two-year combined management of type 2 diabetes (T2DM) on cardiovascular events and all-cause mortality. Methods In the Beijing Community Diabetes Study (BCDS), 441 patients with T2DM in Jinsong community were enrolled in this study. Patients were enrolled in the study from August to December in 2008 and followed up to September 2016 with no cases of exfoliation. Patients were divided into intensive management group (n = 220) and standard management group (n = 221) using random number table. The two groups of patients were managed by GPs under the guidance of the experts of Grade-A and Grade-A hospitals. The patients were regularly followed up and monitored for various indicators to detect complications and intervene early. The differences in management between the two groups were mainly follow-up cycles and the frequency of detection of important indicators: patients in intensive management group were followed up every 2 months, Hb A1c was detected every 3 months, urinary albumin excretion rate (UAER) once every 6 months; patients in the standard management group were followed up every 3 months; Hb A1c was tested every 6 months and UAER was tested once a year. The two groups of patients from 2008 to 2016, the compliance rate of the metabolic indicators and the joint compliance rate, the incidence of end points, analysis of the number of joint compliance on cardiovascular events and all-cause mortality. Results In 2012, the compliance rate of fasting plasma glucose (FPG) was lower in the intensive management group than in the standard management group. The compliance rates of FPG, Hb A1c and LDL-C from 2015 to 2016 were higher than those of the standard management group In 2015, the blood pressure compliance rate was higher than the standard management group, the difference was statistically significant (P <0.05). There were no significant differences in the incidence of all-cause death, cerebrovascular events, cardiovascular events, diabetic nephropathy, diabetic retinopathy, peripheral vascular events, tumor incidence and the total end point events between 2008 and 2016 in both groups (P> 0.05 ). A total of 139 cases (31.5%) of patients with combined compliance ≥ 3 times, the remaining 302 cases (68.5%) combined with the number of compliance <3 times. The incidence of all-cause death, cardiovascular events, and total endpoint events were lower than those of the combined standard scores <3 times (P <0.05). The Log-rank test showed that the combined risk of all-cause death was ≥3, and the risk of cardiovascular events was lower than that of the combined patients (<3 times). The difference was statistically significant (P <0.05). In the 6th year of management, the all-cause death rate and the incidence of cardiovascular events were less than 3 times of the combined standard number of times (P <0.05). Conclusion The joint management of community hospitals and tertiary first-class hospitals can effectively improve the joint compliance rate of T2DM patients. The incidence of all-cause deaths and cardiovascular events in patients with combined compliance ≥ 3 times significantly decreased in the 6th year of management.