内科

目的探讨三级医院主导的多学科团队协同基层链式管理模式在农村糖尿病并发症患者糖尿病知识和血糖管理中的应用效果。方法采用目的抽样法，选取2023年6月至2024年6月4所二级医院和1所一级医院的500例农村糖尿病并发症患者作为研究对象，其中愿意接受三级医院主导的多学科团队协同基层链式管理模式的250例农村糖尿病并发症患者作为观察组，选择常规干预的250例患者作为对照组。两组患者均持续干预12个月。比较两组患者干预前、干预6个月后、干预12个月后的糖尿病（成人）知识量表得分，以及空腹血糖、餐后2 h血糖和糖化血红蛋白水平。结果干预过程中，观察组和对照组分别脱落7例和5例，最终观察组243例、对照组245例患者完成研究。干预前，两组糖尿病（成人）知识量表得分及空腹血糖、餐后2 h血糖、糖化血红蛋白水平差异均无统计学意义（均P>0.05）；干预6个月后、干预12个月后，观察组患者糖尿病（成人）知识量表得分均高于对照组，空腹血糖、餐后2 h血糖和糖化血红蛋白水平均低于对照组（均P<0.05）。结论三级医院主导的多学科团队协同基层链式管理模式可有效提高农村糖尿病并发症患者的糖尿病知识水平，改善其血糖管理效果。

Objective To explore the application effect of a tertiary hospital-led multidisciplinary team combined with primary chain management model in diabetes knowledge and glycemic management among rural patients with diabetes complications. Methods A total of 500 rural patients with diabetes complications from 4 secondary hospitals and 1 primary care institution between June 2023 and June 2024 were selected as study subjects using purposive sampling. Among them, 250 rural patients with diabetes complications willing to be managed by the tertiary hospital-led multidisciplinary team combined with primary chain management model were assigned to the observation group, while 250 patients choosing conventional intervention were assigned to the control group. Both groups received continuous intervention for 12 months. Diabetes Knowledge (Adult) Scale scores, as well as fasting blood glucose (FBG), 2-hour postprandial blood glucose (2hPBG), and glycated hemoglobin (HbA1c) levels, were compared between the two groups before the intervention, 6 months after the intervention, and 12 months after the intervention. Results During the intervention, 7 and 5 patients dropped out from the observation group and control group, respectively. Ultimately, 243 patients in the observation group and 245 in the control group completed the study. Before the intervention, there was no statistically significant difference in the Diabetes Knowledge (Adult) Scale score, or in the level of FBG, 2hPBG, or HbA1c between the two groups (all P>0.05). However, 6 months and 12 months after the intervention, the observation group had higher Diabetes Knowledge (Adult) Scale scores and lower FBG, 2hPBG, and HbA1c levels compared to the control group (all P<0.05). Conclusion The tertiary hospital-led multidisciplinary team combined with primary chain management model can effectively improve diabetes knowledge levels and enhance glycemic management outcomes in rural patients with diabetes complications.

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