To explore the clinical control compliance rate of individual and comprehensive indicators in patients with type 2 diabetes mellitus (T2DM) in the real world.

Since 2017, 13 community health service institutions in Wuhou District that have gradually bound the data of the primary care information business system to the EPM through unique ID information were selected as sample areas. T2DM patients with EPM bound in the sample area were selected as the research subjects. The effective follow-up period, within 1 year outside the effective follow-up period, and more than 1 year outside the effective follow-up period of T2DM patients with glycated hemoglobin (HbA_1c) , low-density lipoprotein cholesterol (LDL-C) , blood pressure follow-up rate, average level, and clinical control compliance rate were recorded. The follow-up rate of comprehensive indicators of 3B (ie HbA_1c, LDL-C, blood pressure) and the rate of clinical control compliance were recorded. The correlation between HbA_1c, LDL-C, blood pressure, 3B comprehensive indicators and the number of T2DM patients managed in different community health service institutions, the correlation between the number of patients with HbA_1c, LDL-C, blood pressure and the effect of each indicator during the effective follow-up period sex were analyzed.

Among the 26 501 contracted T2DM patients, the follow-up rates of HbA_1c, LDL-C, blood pressure and 3B comprehensive indicators during the effective follow-up period were 43.54% (11 539/26 501) , 45.66% (12 101/26 501) , 89.18% (23 633/26 501) and 32.89% (8 715/26 501) , respectively. The follow-up rates of HbA_1c, LDL-C, blood pressure and 3B composite indicators within 1 year outside the effective follow-up period were 15.81% (4 190/26 501) , 24.02 % (6 366/ 26 501) , 9.29 (2 463/26 501) and 0.97% (257/26 501) respectively. The follow-up rates of HbA_1c, LDL-C, blood pressure and 3B comprehensive indicators beyond the effective follow-up period for more than 1 year were 19.20% (5 087/26 501) , 23.41% (6 203/26 501) , 1.28% (339/26 501) and 0.49% (131/26 501) , respectively. During the effective follow-up period, the clinical control rates of HbA_1c, LDL-C, blood pressure and 3B comprehensive indicators were 60.79% (7 015/11 539) , 59.74% (7 229/12 101) , 52.57% (12 423/23 633) and 18.75% (1 634/8 715) , respectively. The clinical control rate of HbA_1c, LDL-C, blood pressure, and 3B comprehensive indicators within 1 year outside the effective follow-up period were 51.98% (2 178/4 190) , 56.75% (3 613/6 366) , 47.79% (1 177/2 463) and 14.79% (38/257) , respectively. The clinical control rates of HbA_1c, LDL-C and blood pressure beyond the effective follow-up period for more than 1 year were 65.62% (3 338/5 087) , 59.46% (3 688/6 203) and 22.71% (77/339) , respectively. There was a high correlation between the blood pressure clinical control compliance rate and the 3B comprehensive index clinical control compliance rate (r=0.949, P<0.01) . HbA_1c (r=0.648) , LDL-C (r=0.867) , blood pressure (r=0.988) , and the number of 3B comprehensive indicators (r=0.712) were positively correlated with the number of T2DM patients managed in different community health service institutions within the validity period (P<0.05) . The mean LDL-C was negatively correlated with the number of managed cases of T2DM patients (r=-0.715, P<0.01) , and the number of clinically controlled cases (r=0.888) and the rate of clinically controlled compliance (r=0.704) were positively correlated with the number of managed cases of T2DM patients (P<0.05) . Blood pressure (r=0.791) , the number of clinically controlled cases of 3B comprehensive indicators (r=0.616) were positively correlated with the number of managed cases of T2DM patients (P<0.05) . The standard deviation of HbA_1c was negatively correlated with the number of HbA_1c follow-up cases within the validity period (r=-0.708, P<0.01) , and the number of clinically controlled cases was positively correlated with the number of HbA_1c follow-up cases within the validity period (r=0.943, P<0.01) . The average LDL-C value was negatively correlated with the number of LDL-C follow-up cases within the validity period (r=-0.716, P<0.01) , and the number of clinically controlled cases and the clinical control compliance rate were positively correlated with the number of LDL-C follow-up cases within the validity period (r=0.986, r=0.657, P<0.05) . There was a positive correlation between the number of blood pressure clinical control patients and the number of blood pressure follow-up cases within the validity period (r=0.839, P< 0.01) .

The individual and comprehensive control levels and control rates of 3B indicators in sample areas are higher, and the differences among institutions are small. The service quality of district as a unit is highly balanced, but there is still a large space for improvement of evidence-based management behavior of lost population.

探索真实世界2型糖尿病（T2DM）患者临床单项和综合指标临床控制达标率情况。

选取自2017年起，武侯区逐步将基层医疗信息业务系统数据通过唯一的身份证信息绑定在签约患者健康管理系统（EPM）中的13家社区卫生服务机构为样本区。选择样本区绑定EPM的T2DM患者为研究对象。记录患者有效随访期、有效随访期外1年内、有效随访期外1年以上T2DM患者糖化血红蛋白（HbA_1c）、低密度脂蛋白胆固醇（LDL-C）、血压随访率、平均水平以及临床控制达标率，记录3B（即HbA_1c、LDL-C、血压）综合指标随访率及临床控制达标率。对不同社区卫生服务机构HbA_1c、LDL-C、血压、3B综合指标与T2DM患者管理例数进行相关性分析，同时分析有效随访期随访HbA_1c、LDL-C、血压患者例数与各指标效果间相关性。

26 501例签约T2DM患者中，有效随访期HbA_1c、LDL-C、血压和3B综合指标随访率分别为43.54%（11 539/26 501）、45.66%（12 101/26 501）、89.18%（23 633/26 501）和32.89%（8 715/26 501）；有效随访期外1年内HbA_1c、LDL-C、血压和3B综合指标随访率分别为15.81%（4 190/26 501）、24.02 %（6 366/26 501）、9.29%（2 463/26 501）和0.97%（257/26 501）；有效随访期外1年以上HbA_1c、LDL-C、血压和3B综合指标随访率分别为19.20%（5 087/26 501）、23.41%（6 203/26 501）、1.28%（339/26 501）和0.49%（131/26 501）。有效随访期内HbA_1c、LDL-C、血压、3B综合指标临床控制达标率分别为60.79%（7 015/11 539）、59.74%（7 229/12 101）、52.57%（12 423/23 633）、18.75%（1 634/8 715）；有效随访期外1年内HbA_1c、LDL-C、血压、3B综合指标临床控制达标率为51.98%（2 178/4 190）、56.75%（3 613/6 366）、47.79%（1 177/2 463）、14.79%（38/257）；有效随访期外1年以上HbA_1c、LDL-C、血压临床控制达标率分别为65.62%（3 338/5 087）、59.46%（3 688/6 203）、22.71%（77/339）。血压临床控制达标率与3B综合指标临床控制达标率的相关性高（r=0.949，P<0.01）。不同社区卫生服务机构有效期内随访HbA_1c（r=0.648）、LDL-C（r=0.867）、血压（r=0.988）、3B综合指标例数（r=0.712）与T2DM患者管理例数呈正相关（P<0.05）。LDL-C平均值与T2DM患者管理例数呈负相关（r=-0.715，P<0.01），临床控制达标例数（r=0.888）、临床控制达标率（r=0.704）与T2DM患者管理例数呈正相关（P<0.05）。血压（r=0.791）、3B综合指标临床控制达标例数（r=0.616）与T2DM患者管理例数呈正相关（P<0.05）。HbA_1c标准差与有效期内HbA_1c随访例数呈负相关（r=-0.708，P<0.01），临床控制达标例数与有效期内HbA_1c随访例数呈正相关（r=0.943，P<0.01）。LDL-C平均值与有效期内LDL-C随访例数呈负相关（r=-0.716，P<0.01），临床控制达标例数、临床控制达标率与有效期内LDL-C随访例数呈正相关（r=0.986、0.657，P<0.05）。血压临床控制达标例数与有效期内血压随访例数呈正相关（r=0.839，P<0.01）。

样本区3B综合指标单项和综合控制水平和临床控制达标率高，且在机构间差异较小，以区为单位的糖尿病健康管理服务质量均衡性高，但仍有较大未随访人群需进行管理完善。