| Objective:On the basis of understanding the current situation of primary health institutions,community Type 2 diabetes(T2DM)health management and related indicators of patients,a hospital-community integrated diabetes management model was established and applied in the pilot areas.The changes of the infrastructure of primary health institutions and the changes of various indicators of T2DM patients in the pilot areas before and after the implementation of the model were evaluated as a whole.A control area was set up to study the role of this model in T2DM disease management through the changes of the overall probability of T2DM complications in the pilot area and the control area,in order to provide an effective model and an effective evaluation model for the prevention and control of chronic diseases such as T2DM,and to provide a scientific basis for exploring effective measures and evaluation methods for health management of diabetes.Method:1.The community health service center(CHCs)in Urumqi high-tech zone(new urban area)was visited and investigated,and the relevant information was collected through quantitative questionnaire survey,the basic situation of 12 CHCs was analyzed by descriptive statistical method,and the medical cooperation plan between high-tech zone(new urban area)and the first affiliated Hospital of Xinjiang Medical University was constructed.2.3250 residents of Urumqi high-tech zone(new urban area)were randomly selected for T2DM and risk factors questionnaire survey.T-test,analysis of variance and chi-square test were used to analyze the prevalence and awareness rate of T2DM among community residents.3.Through the methods of literature review,investigation and expert consultation,the hospital-community integrated diabetes management model was established and applied to the pilot community high-tech zone(new urban area).The basic construction at the institutional level adopts the method of comparing the actual frequency,while at the patient level,the follow-up data of 2010 T2DM patients are collected every quarter after the implementation of the model for a total of 8 times.T-test,analysis of variance,chi-square test and logistics regression were used to compare the data and analyze the influencing factors.4.Based on the follow-up data of T2DM patients in Urumqi,the evaluation index calculation system was constructed by Lasso regression and logistics regression analysis.The probability of T2DM complicated with microvascular complications(T2DM+MVD)in the pilot community and control area before and after the implementation of the calculation model was the most evaluated index.Intermittent time series analysis and double difference method were used to analyze the correlation between the implementation of the model and the fluctuation of evaluation indicators to evaluate the effect of hospital-community integrated diabetes management model on the tertiary prevention of T2DM.Results:1.The basic situation of 12 CHCs in 2016:the population of the covered area reached325948,the total area of business space was 18018 square meters,the total number of open beds was 320,and the number of employees on duty was 435.The number of junior college and undergraduate students on duty is 195,161,accounting for 44.8%and 37%of the total,respectively;Diabetes management:the number of CHCs diabetes patients in 12 high-tech zones(new urban areas)is about 34027;the number of patient files is 10717,and the standardized filing rate is 31.64%;resource allocation:CHCs T2DM managers are all part-time,and the basic facilities related to T2DM can meet the standards.In 2016,12 CHCs in high-tech zones(new urban areas)held a total of 307 lectures on diabetes health knowledge for patients,and in 2016,the community organized medical staff to conduct special training on diabetes for a total of 71 times.2.The prevalence rate of T2DM in high-tech zones(new urban areas)in 2016 was10.41%,of which the prevalence rate of males(12.29%)was higher than that of females(9.00%).The prevalence rate of diabetes increased with the increase of age and decreased with the improvement of education.The prevalence rate of T2DM complications in T2DM patients was 34.69%,among which there were more T2DM patients with cardiovascular disease and retinopathy,which were 13.44%and 13.75%,respectively.3.In the five years before and after the implementation of the model,the CHCs service population in high-tech zones(new urban areas)showed a downward trend,with a service population of 391390 by 2020,of which 2017 was the period with the largest service population,with 500181;fixed assets showed an upward trend from 2016 to 2019,which was basically the same as that in 2020;and the area of business housing showed an upward trend in the past 5 years,from 18018m~2 in 2016 to 30600.7m~2 in 2020.Approved beds and open beds have increased year by year from 2016 to 2019,2019 is equivalent to the approved beds in 2020,and open beds have decreased slightly.4.After two years of standardized management of hospital-community integration model,the compliance rates of fasting blood glucose,two-hour postprandial blood glucose,total cholesterol,triglyceride,high density lipoprotein cholesterol and low-density lipoprotein cholesterol were increased(P<0.05).In terms of life style(smoking,drinking,exercise frequency,exercise duration,staple food),the patients’BMI decreased significantly after management,and the patients’blood sugar was significantly increased after management,and the drug compliance and medical compliance behavior were significantly improved,and the psychological aspects of the patients were also greatly improved(P<0.05).The results showed that the patients’life style(smoking,drinking,exercise frequency,exercise time,staple food)improved better after management,and the number of patients taking medicine to control blood sugar increased significantly(P<0.05).90.60%of the patients were satisfied with the control after management.Among them,the increase of age,education level,exercise frequency,and the improvement of medication compliance and medical compliance were the satisfactory protective factors for follow-up control.The course of disease is long and there are many complications.Substandard blood glucose,lack of diet control,increase of staple food intake and BMI were risk factors for satisfactory follow-up control.5.Lasso regression screened 13 variables,logistics regression analysis showed that age was not statistically significant,the other 12 variables were statistically significant,the protective factors were psychological regulation and medication compliance,and the OR(95%CI)of general and poor psychological adjustment,good and poor were 0.69(0.56,0.83)and 0.58(0.48,0.70),respectively.The OR(95%CI)of intermittent and non-medication compliance,regular and non-medication compliance were 0.82(0.68,0.99)and1.22(1.13,1.32)respectively(P<0.05).The risk factors were family history of diabetes,hypertension,myocardial infarction of coronary heart disease,stroke,postprandial blood glucose,fasting blood glucose and urinary microalbuminuria.OR(95%CI)was the highest in stroke and urinary microprotein,5.62(5.16,6.12)and 5.12(4.47,5.86)respectively(P<0.05).Dietary control,oral hypoglycemic drugs,use of insulin and alcohol restriction still showed a higher risk of T2DM+MVD in patients with diabetes and the risk of developing T2DM+MVD was higher in patients with diabetes who took the above measures,OR(95%CI)was 2.05(1.94,2.18),1.38(1.3,1.46),),2.16(2.06,2.26),1.49(1.41,1.56)respectively(P<0.05).6.The piecewise regression model of intermittent time series analysis showed that the changes before,after and before the implementation of the model were not correlated with the implementation of the model in the control area and pilot area,and the hypothesis test of each coefficient was not statistically significant(P>0.05).According to the observation of the trend of the two places by the direct observation method,we can see that the baseline trend of the high-tech zone(new urban area)in the pilot area is higher than that in the control area,and the gap between the two places decreases with the passage of time.The overall probability of T2DM+MVD in the pilot area is lower than that in the control area one year after the implementation of the model.The double difference model analysis showed that there was significant difference between the pilot area and the control area before the implementation of the model(P<0.01),but there was no significant difference after the control of the covariable(P<0.01).Before the control of the covariable,the difference of the evaluation index before and after the implementation of the model in the pilot area was statistically significant(P<0.01).There were significant differences in the evaluation index before and after the implementation of the model(P<0.01,P=0.0272).Before and after the control of covariates,there were significant differences in the evaluation indexes between the pilot area and the control area before and after the implementation of the covariates.The coefficients were-0.0049 and-0.0030,respectively.Conclusion:1.There are many similarities between the epidemiological characteristics of diabetes in the community and the overall epidemiological characteristics of diabetes,because of its high feasibility in the implementation of standardized management measures,it is an ideal pilot to explore diabetes prevention and control measures.However,at present,there are still some problems,such as low academic qualifications and professional titles of CHCs staff,lack of T2DM managers,few times of special training on T2DM management for medical staff,shallow content and so on.The current situation of CHCs in the pilot area and the characteristics of diabetes in the community suggest that when formulating a hospital-community integrated diabetes management plan,efforts should be made to improve the skills of grass-roots medical workers,patients’self-management ability and promote graded diagnosis and treatment to drive the sinking of hospital advantage resources.2.Hospital-community integrated diabetes management model has a certain role in promoting the capacity of CHCs in pilot areas,but it does not have a lasting effect,and long-term intervention is still needed.The hospital-community integration model has advantages in diabetes management,and primary health service is an important factor affecting patient satisfaction,suggesting that improving the ability of grass-roots health services and exploring disease management model is sometimes the key means to improve disease health management.it is one of the effective ways of disease prevention and control.3.When exploring the effect of hospital-community integrated diabetes management model on the third-level prevention of T2DM in CHCs,the follow-up data of comprehensive primary health work can be used as the evaluation index database.The probability value calculated by establishing diabetes complication risk prediction model based on this database is a more reliable evaluation index.In the process of calculating the evaluation index,it was found that stroke and urinary microprotein were important risk factors for T2DM+MVD,while the service contents of primary health workers such as psychological evaluation and drug compliance were protective factors for T2DM+MVD,and diet control,alcohol restriction and insulin use were lan T2DMarks for severe patients when the implementation area of mild patients was small.Hospital-community integrated diabetes management model for the prevention and control of diabetic complications has not been observed immediate effect,but there are more obvious long-term effects worth popularizing. |
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