重庆市社区糖尿病干预现状及新型模式研究

发布时间：2018-07-21 16:39

【摘要】：背景:根据国际糖尿病联盟(International Diabetes Federation,IDF)的最新估计,2015年全球约有4.15亿的糖尿病(Diabetes Mellitus,DM)患者,预计在2040年将达到6.42亿。中国几次大型流行病学调查显示,在过去30年,糖尿病患病率从1980年的0.7%快速上升至2010年的11.6%,患者人数超过欧美、印度等国家,成为全球糖尿病患者最多的国家,更值得关注的是,中国18岁及以上成年人处于糖尿病前期(Prediabetes,PDM)的比例高达50.1%。如果不加以任何干预,每年将有5~10%的糖尿病前期患者发展为糖尿病。糖尿病已成为21世纪全球最重要的公共卫生问题之一,尤其是2型糖尿病(Type 2 diabetes,T2DM)的防治面临着前所未有的挑战。糖尿病的预防与控制技术得到世界卫生组织(World Health Organization,WHO)和各国政府的高度关注。除了药物治疗,大量研究证实行为干预有助于患者的血糖控制,根据中国《2型糖尿病患者健康管理服务规范》要求,目前,中国所有确诊的T2DM患者均接受基层医疗卫生机构提供的综合干预。如何提高干预效力,进一步提升干预效果成了干预研究的关键点和难点。近年来,一些整合社会人际资源和社会技术平台的方法在糖尿病干预中展示出良好的应用前景,其中同伴支持、结合互联网和电讯网络的信息发布与联系的新模式在提高患者依从性、节省资源方面独具特色。目的:1)评估现行社区为基础的2型糖尿病综合干预模式在大人群中运用的可行性和有效性。2)科学合理地评价同伴支持对2型糖尿病患者血糖控制的实施效果,为后续研究提供理论基础。3)完成以同伴支持、信息技术平台为基础的糖尿病前期患者行为干预模型的基础构建。方法:1)对重庆市7200例T2DM患者按照《2型糖尿病患者健康管理服务规范》要求进行为期1年的社区为基础的综合干预,通过干预前后各项评估指标的改变对实施效果进行评估。评估指标包括空腹血糖(fastingplasmaglucose,fpg)、血糖控制达标率,以及糖尿病防治相关知识、态度和行为(knowledgeattitudepractice,kap)等。2)系统性地检索“相关期刊论文”、“中国生物医学文献数据库”、vip、medline,embase,cochranecollaborativedatabase等数据库,搜素同伴支持进行t2dm干预的随机对照研究(randomizedcontrolledtrial,rct),用meta分析方法进行数据的合并。采用cochrane协作网的偏倚风险评价工具对纳入的所有随机对照研究进行风险评估,使用reviewmanager5.2和stataversion12.1软件进行统计分析,以干预组和对照组干预前后糖化血红蛋白(glycatedhemoglobina1c,hba1c)变化值的差值(即平均差),及其95%可信区间(95%confidenceinterval,95%ci)作为判定同伴支持干预效果的评价指标。根据研究地区、研究对象基线hba1c水平、干预时间、干预频率、干预模式等进行亚组分析。3)根据行为干预理论构建新型糖尿病前期患者行为干预模型;通过定性研究构建行为干预任务、内容;在有代表性的社区建立干预队列;干预组建立以同伴支持和信息化技术为基础的干预网络。进一步观察干预组与对照组的可比性为前瞻性观察提供依据;在干预模型基础建设完成的同时,初步观察干预队列的行为转变,了解其依从性。结果:1)6586名t2dm患者完整的接受了1年的社区为基础的综合干预,患者空腹血糖平均值由干预前的8.52±2.84mmol/l降至干预后的7.44±2.06mmol/l,血糖控制达标率由27.18%显著上升至52.82%;糖尿病防治相关知识的7项核心指标知晓率从39.95%~74.83%上升至72.50~85.44%;规范化药物治疗、坚持非药物治疗和每周坚持1次以上血糖监测的比例分别由19.48%、19.02%和18.78%上升到75.19%、67.42%和41.62%。接受干预后,农村地区和小学及以下文化程度患者空腹血糖平均值分别为7.77mmol/l±2.27mmol/l和7.60mmol/l±2.21mmol/l,显著高于城市和初中及以上文化程度的患者;血糖控制达标率分别为44.8%和49.7%,显著低于城市和初中及以上文化程度的患者。2)共检索3223篇文献,最终纳入13篇同伴支持进行t2dm干预的随机对照研究,涉及1352名研究对象。meta分析结果显示:各研究间存在高度异质性(i2=80.0%),因此选用随机效应模型进行结果的合并。干预前后,干预组hba1c的改变值显著高于对照组的改变值:平均差为-0.57(95%ci-0.78~-0.36),差异有统计学意义(p0.001)。亚组分析结果显示:干预前hba1c处于高(≥8.5%)、中水平(7.5%~8.5%)的研究对象接受干预后,hba1c改变值高于对照组干预前后的改变值,平均差分别为-0.78(-1.06~-0.51)和-0.76(-1.05~-0.47),而干预前hba1c水平较低者(7.5%),干预组和对照组干预前后hba1c改变值差异无统计学意义,平均差为-0.08(-0.32~0.16);在干预频率方面,实施中、高频率的干预(1-2次/月或≥2次/月)均显示出干预组hba1c降低值明显高于对照组,平均差分别为-0.52(-0.60~-0.44)和-0.75(-1.21~-0.29),但低频率的干预(1次/月)则显示干预组与对照组干预前后hba1c改变值差异无统计学差异,平均差为-0.32(-0.74~0.09);干预方式方面,个体化的干预实施效果(平均差为-0.91)显著高于群体性(平均差为-0.42)或混合性(平均差为0.52)的干预方式,大部分个体化干预项目均由同伴支持者通过电话或短信方式实施干预;根据发表年份、干预模式、研究实施地点以及干预持续时间等进行亚组分析,各亚组间差异均无统计学意义。3)设计了有针对性的行为干预菜单(即干预包),涉及运动、饮食、养身3个主题,10个具体行为任务;建立研究队列包括干预组285人,对照组237人;对干预组建立了涉及社区工作人员、家属、患者同伴、健康伴铃4层的“同伴支持”网络,以及整合电话、短信、qq、微信等技术手段的信息交流平台。分析结果显示,两组研究对象在文化、经济、性别、年龄构成、基础血糖、血脂水平等指标上具有可比性;经过连续8周的干预,干预组研究对象部分行为指标显著改善。结论:1)对t2dm患者实施为期1年的社区为基础的综合管理,有效降低了患者空腹血糖水平,提高了血糖控制达标率,但总体控制率仍偏低。应进一步加大工作力度,探索新措施来弥补现有综合管理模式的不足,整体推进t2dm防治工作。2)目前的综合管理项目实施效果受到多种因素的影响。与城市和文化程度较高的患者相比,农村地区和文化程度偏低的糖尿病患者血糖水平更高、防治知识匮乏、规范化药物治疗和非药物治疗以及坚持血糖监测的比例更低。因此,对不同人群应该适当调整干预策略和方式。3)同伴支持干预模式在世界范围内展示出良好的应用前景,能促进t2dm患者hba1c水平降低,患者基础hba1c水平以及干预频率的高低是影响干预效果的重要因素。为提高同伴支持的干预效果,应优先选择在血糖控制不良的t2dm患者中进行干预,且干预频率至少达到1次/月以上。研究中发现的以电话或手机短信为基础的干预模式可能是今后降低糖尿病患者血糖控制成本的有效手段。4)结合多重同伴支持及信息交流网络的新型干预方法,整合了现有社会支持和资源,节省人力、物力,糖尿病前期人群接受程度较好。进一步的效果评估将为重庆地区糖尿病防控的新型干预技术提供决策支持。5)预防糖尿病的主观意识薄弱,行为依从性差是糖尿病前期患者的重要特征。利用条件成熟、易于实现的行为干预内容,或者对重要行为干预内容设计更为细致的作用环节是提高依从性的可行方法。此外,以糖尿病患者家庭为核心,将其中的前期患者纳入干预队列有利于提高干预效率。
[Abstract]:Background: according to the latest estimates of the International Diabetes Federation (IDF), about 415 million of the world's Diabetes Mellitus (DM) patients worldwide in 2015 are expected to reach 642 million in 2040. Several large epidemiological surveys in China have shown that the prevalence of diabetes has risen from 0.7% to 20 in the last 30 years in the last 30 years. 10 years of 11.6%, the number of patients over the United States and Europe, India and other countries, the world's most diabetic countries, more attention is that China's 18 years and older adults in the prediabetes (Prediabetes, PDM) in the proportion of up to 50.1%. if no intervention, each year will have 5~10% diabetic patients to develop diabetes. Urinary disease has become one of the most important public health problems in the world in the twenty-first Century, especially the prevention and control of type 2 diabetes (Type 2 diabetes, T2DM). The technology of prevention and control of diabetes is highly concerned by the WHO (World Health Organization, WHO) and the governments of all countries. According to the requirements of the standard of health management service for patients with type <2 diabetes in China, all of the confirmed T2DM patients in China accept the comprehensive intervention provided by the grass-roots medical and health institutions. How to improve the effectiveness of intervention and further raise the effect of intervention has become the key point and difficulty of intervention research. In recent years, some methods of integrating social interpersonal resources and social technology platform have shown good prospects for the application of diabetes intervention. The new model of peer support and information release and contact with Internet and telecommunications networks is unique in improving patient compliance and saving resources. Objective: 1) assessment of the current community Based on the feasibility and effectiveness of the integrated intervention model of type 2 diabetes in the large population (.2), a scientific and rational evaluation of the effect of peer support on blood glucose control in patients with type 2 diabetes and a theoretical basis for follow-up study.3) to complete the behavioral intervention model of prediabetes patients based on the peer support and information technology platform Basic construction. Methods: 1) 7200 cases of T2DM patients in Chongqing were given a comprehensive community based intervention based on the standard of health management service for type <2 diabetic patients for a period of 1 years. The effect was evaluated by the changes of the evaluation indexes before and after intervention. The evaluation index included fastingplasmaglucose (FPG) and blood sugar. Control the standard rate, and diabetes prevention and control related knowledge, attitude and behavior (knowledgeattitudepractice, KAP) and other.2) systematically retrieving the "Chinese journal full text database", "Chinese Biomedical Literature Database", VIP, MEDLINE, EMBASE, cochranecollaborativedatabase and other databases, search for peer support for the randomness of T2DM intervention The control study (randomizedcontrolledtrial, RCT) was used to combine the data with the meta analysis method. All the randomized controlled studies were evaluated by the bias risk assessment tool of the Cochrane Collaboration Network, and the reviewmanager5.2 and stataversion12.1 software were used for statistical analysis to make the intervention group and the control group glycated before and after intervention. The difference value (glycatedhemoglobina1c, HbA1c) variation value (mean difference), and its 95% confidence interval (95%confidenceinterval, 95%ci) were used as evaluation indexes to determine the effect of peer support intervention. According to the study area, the baseline HbA1c level, intervention time, intervention frequency, intervention model, and other subgroup analysis.3) based on the behavior according to the study area. The intervention theory was established for the behavior intervention model of the new-type prediabetes patients; the intervention task was constructed by qualitative research; the intervention queue was set up in the representative community; the intervention group established the intervention network based on peer support and information technology. Supply basis; at the same time in the completion of the intervention model construction, a preliminary observation of the behavior change of the intervention cohort and understanding of its compliance. Results: 1) 6586 T2DM patients received a complete comprehensive intervention based on 1 years of community. The average value of fasting blood glucose decreased from 8.52 + 2.84mmol/l before intervention to 7.44 + 2.06mmol/l after intervention, and the blood glucose control was controlled. The standard rate increased from 27.18% to 52.82%; the awareness rate of 7 core indicators for diabetes prevention and control increased from 39.95%~74.83% to 72.50~85.44%; standardized drug treatment, non drug therapy, and the percentage of persisting more than 1 times per week increased from 19.48%, 19.02% and 18.78% to 75.19%, 67.42% and 41.62%., respectively. After that, the average fasting blood glucose of patients in rural areas and primary schools and below was 7.77mmol/l + 2.27mmol/l and 7.60mmol/l + 2.21mmol/l, respectively, which were significantly higher than those of urban and junior high school or above. The standard rate of blood glucose control was 44.8% and 49.7% respectively, which was significantly lower than those of urban and junior high school and above education. A randomized controlled study of 13 peer support for T2DM intervention was included in 3223 papers. The results of.Meta analysis of 1352 subjects showed that there was a high heterogeneity (i2=80.0%) in each study, so the random effect model was used to merge the results. The change value of HbA1c in the intervention group was significantly higher than that of the control group before and after intervention. The mean difference was -0.57 (95%ci-0.78~-0.36), and the difference was statistically significant (p0.001). The results of subgroup analysis showed that before intervention, HbA1c was higher (more than 8.5%), and the middle level (7.5%~8.5%) subjects received the dry prognosis. The change values of HbA1c were higher than those of the control group before and after intervention, the average difference was -0.78 (-1.06~-0.51) and -0.76 (-1.05~-0.47), respectively. Before and after intervention (7.5%), there was no significant difference in HbA1c change values between the intervention group and the control group before and after intervention, the mean difference was -0.08 (-0.32~0.16). In the frequency of intervention, the intervention of high frequency (1-2 / month or more than 2 times / month) showed that the HbA1c reduction of the intervention group was significantly higher than that of the control group, and the mean difference was -0.52 (-0.6, -0.6, respectively, -0.6). 0~-0.44) and -0.75 (-1.21~-0.29), but low frequency intervention (1 / month) showed that there was no statistical difference between the intervention group and the control group before and after the intervention, and the mean difference was -0.32 (-0.74~0.09). The individual intervention effect (Ping Juncha -0.91) was significantly higher than that of the group (mean difference -0.42) or mixed sex (mean difference). The difference was 0.52). Most of the individual intervention programs were intervened by the partner supporters by telephone or SMS. According to the published years, the intervention model, the study site and the duration of the intervention, the subgroups were analyzed, and the different subgroups were all without the.3). The intervention package, involving 3 subjects of exercise, diet and health care, 10 specific behavioral tasks, and the establishment of a study cohort including 285 people in the intervention group and a control group of 237, established a "peer support" network involving the community staff, family members, patient partners, and healthy companion bell 4 layers, as well as the integrated telephone, SMS, QQ, WeChat and other technical means. The results showed that the two groups of subjects were comparable in cultural, economic, gender, age, basic blood glucose and blood lipid levels. After 8 weeks of intervention, the behavioral indicators of the subjects were significantly improved. Conclusion: 1) the implementation of a comprehensive management based on the community for a period of 1 years for T2DM patients was effective. Reduce the level of fasting blood glucose in patients, improve the rate of blood glucose control, but the overall control rate is still low. We should further strengthen the work, explore new measures to make up the deficiency of the existing comprehensive management model, and promote the overall T2DM prevention and control work.2) the current comprehensive management project effect is affected by a variety of factors, and the city and culture. Higher levels of patients have higher levels of blood sugar in rural and less educated diabetics, lack of knowledge of prevention and control, standardized drug treatment and non drug treatment, and the lower proportion of adherence to blood glucose monitoring. Therefore, the intervention strategy and.3 of different populations should be properly adjusted and the peer support intervention model is worldwide The good prospect of application can promote the decrease of HbA1c level in T2DM patients. The level of basic HbA1c and the frequency of intervention are important factors that affect the effect of intervention. In order to improve the intervention effect of peer support, priority should be given to intervention in T2DM patients with poor blood glucose control, and the frequency of intervention is at least 1 times per month. The intervention model based on telephone or cell phone SMS may be an effective means to reduce the cost of diabetes control in the future,.4) combined with the new intervention method of multiple peer support and information communication network, integrating the existing social support and resources, saving manpower, material resources, and the acceptance of pre diabetes population. Better. Further evaluation will provide decision support for the new intervention technologies for diabetes prevention and control in Chongqing. The subjective awareness of diabetes prevention is weak. Poor compliance is an important feature of pre diabetes patients. Use of mature, easy to implement behavior intervention, or more important behavior intervention content design more. Careful action is a feasible way to improve compliance. In addition, the inclusion of early patients in the intervention cohort in the family of diabetic patients is beneficial to the improvement of the intervention efficiency.
【学位授予单位】：第三军医大学
【学位级别】：博士
【学位授予年份】：2016
【分类号】：R587.1

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