Endocrine Abstracts

Background: Diabetes prevalence and mortality are increasing rapidly and glycemic goals (hemoglobin A1c < 7%) are often not achieved in patients with type 2 diabetes in China, The low control rate of diabetes has become a global problem. The management of community diabetes is the most effective choice to prevent and control chronic diseases.

Objective: To improve the management of diabetes mellitus in community, we analyze the effect of hospital-community integrated management.

Method: 541 cases diabetic patients in a suburb community of shanghai from April 2014 to April 2015 were cared with hospital-community integrated management, Include community blood glucose monitoring and regular diabetes education, hospital experts guide the treatment of community doctors etc, and the clinical and laboratory data before and after management was collected, and the control rate of HbAlc, blood pressure, blood lipids and related factors were analyzed.

Results: After one year management, patients with diabetes compared to baseline HbA (%), FPG, 2hPG, HOMA-IR, SBP, DBP, TG, LDL-C, Waist indexes have significant decline (P<0.05). the control rates of HbA, blood pressure, blood lipid were increased from 63.40%, 9.98%, 50.46% respectively to 72.27%, 22.18%, 58.96% (P<0.05), and the control rates of single, two, three indexes of HbA, blood pressure, blood lipid were all increased from 62.84%, 2.49%, 3.18% respectively to 69.13%, 12.93%, 33% (P<0.05).Multivariate Logistic regression analysis shows lack of exercise and control of diets, lower frequency of monitoring blood glucose in community and high systolic blood pressure and triglyceride levels are risk factors of reduction the target rate of HbA to diabetic patients; Age, persons with a lower educational level and high HbA and triglyceride levels are risk factors of decreasing the target rate of hypertension to diabetic patients; Lack of exercise and regular pharmacologic treatment and lower frequency of monitoring blood glucose in community are risk factors of decreasing the target rate of blood lipids to diabetic patients.

Conclusion: The integrated management of hospital and community can improve the control rate of blood glucose, blood pressure and blood lipid in shanghai community, strengthening the blood glucose monitoring in community is an effective method of chronic diseases management of diabetes mellitus