Servicio de Endocrinología y Nutrición, Instituto de Investigación e Innovación Biomédica de Cádiz (INIBICA). Hospital Universitario Puerta del Mar, Cádiz, España.
Departamento de Medicina, Facultad de Medicina, Universidad de Cádiz, Cádiz, España.
Endocrinol Diabetes Nutr (Engl Ed). 2021 Mar;68(3):175-183. doi: 10.1016/j.endinu.2019.12.010. Epub 2020 Jun 3.
Diabetes mellitus (DM) is one of the most prevalent chronic diseases and has a significant health and social impact. Strict control of blood glucose levels and other risk factors for vascular disease reduces complications and mortality and is related to the quality of care received. Although care should be interdisciplinary, based on the coordination of primary care (PC) and hospital care (HC), little information is available on the effectiveness of the different existing intervention models.
To assess, in a population with DM from a healthcare area, the impact on health, quality of care, and effectiveness in the use of resources of a specific model of shared management of patients with DM (Instrument for Evaluation of Models of Chronic Care in Diabetes Mellitus; IEMAC-DM).
A quasi-experimental before-after intervention study in patients with DM in the Cádiz-San Fernando Healthcare Area (Andalusia, Spain) that allows for identifying the capacity of the program to improve the quality indicators both in the whole population with DM and in that referred to HC. For this, a working group consisting of healthcare professionals of different profiles and care levels was set up. An initial self-assessment was done using the IEMAC-DM tool and, after analysis of the preliminary results, improvement strategies were established and implemented. Finally, the clinical and resource management results were assessed before and two years after the implementation of the model.
During the study period, no significant changes were seen in process indicators related to laboratory practices or examinations in the health area. The proportion of patients with acceptable metabolic control [glycosylated hemoglobin (HbA1c) level<8%] was 49% in 2015 and 45% in 2017. The number of admissions related to acute myocardial infarction and stroke remained constant, but there was an increase in the standardized ratio of major lower limb amputations (1.5 vs. 1.9). Of the 295 patients referred from PC to HC, the proportion of adequate referrals increased from 40% in 2015 to 76% in 2017 (p=0.001). In the referred patients, a significant improvement was seen in the mean difference in glycosylated hemoglobin levels (HbA1c; 1.14±1.73%; 95% CI: 0.73-1.55; p=0.0001) and cholesterol (11.28±40mg/dL; 95% CI: 2.07-20.48; p=0.012).
This study shows that an intervention based on a chronicity care model adapted to patients with DM improves certain aspects related to the quality of care and the degree of metabolic control. Improving health outcomes will require long-term evaluation and, probably, other additional interventions.
糖尿病（DM）是最常见的慢性疾病之一，对健康和社会都有重大影响。严格控制血糖水平和其他血管疾病风险因素可降低并发症和死亡率，并与所接受的护理质量有关。尽管护理应该是跨学科的，基于基层医疗（PC）和医院护理（HC）的协调，但关于不同现有干预模式的有效性的信息很少。
在一个来自医疗保健区域的 DM 患者人群中，评估特定的 DM 患者共同管理模型（糖尿病慢性护理模型评估工具；IEMAC-DM）对健康、护理质量和资源使用效果的影响。
这是一项在卡迪斯-圣费尔南多医疗保健区域（西班牙安达卢西亚）的 DM 患者中进行的准实验性干预前后研究，该研究可确定该计划改善整个 DM 患者人群和转诊至 HC 的患者人群的质量指标的能力。为此，成立了一个由不同专业和护理水平的医疗保健专业人员组成的工作组。使用 IEMAC-DM 工具进行了初始自我评估，在分析初步结果后，制定并实施了改进策略。最后，在实施模型之前和两年后评估临床和资源管理结果。
在研究期间，与实验室实践或健康区域检查相关的过程指标没有明显变化。可接受代谢控制的患者比例[糖化血红蛋白（HbA1c）水平<8%]在 2015 年为 49%，在 2017 年为 45%。与急性心肌梗死和中风相关的住院人数保持不变，但主要下肢截肢的标准化比率有所增加（1.5 比 1.9）。在从 PC 转诊至 HC 的 295 名患者中，适当转诊的比例从 2015 年的 40%增加到 2017 年的 76%（p=0.001）。在转诊患者中，糖化血红蛋白水平（HbA1c）的平均差值显著改善（1.14±1.73%；95%CI：0.73-1.55；p=0.0001）和胆固醇（11.28±40mg/dL；95%CI：2.07-20.48；p=0.012）。
这项研究表明，基于适应 DM 患者的慢性病护理模型的干预可改善与护理质量和代谢控制程度相关的某些方面。改善健康结果需要长期评估，可能还需要其他额外的干预措施。
