Zarora Reetu, Immanuel Jincy, Chivese Tawanda, MacMillan Freya, Simmons David
School of Medicine, Western Sydney University, Diabetes Obesity and Metabolism Translational Research Unit, Macarthur Clinical School, Campbelltown, New South Wales, AU.
Department of Population Medicine, College of medicine, QU Health Qatar University, Doha, QA.
Int J Integr Care. 2022 May 12;22(2):11. doi: 10.5334/ijic.6025. eCollection 2022 Apr-Jun.
Evidence that integrated diabetes care interventions can substantially improve clinical outcomes is mixed. However, previous systematic reviews have not focussed on clinical effectiveness where the endocrinologist was actively involved in guiding diabetes management.
We searched EMBASE, COCHRANE, MEDLINE, SCOPUS, CINAHL, Google Scholar databases and grey literature published in English language up to 25 January 2021. Reviewed articles included Randomised Controlled Trials (RCTs) and pre-post studies testing the effectiveness on clinical outcomes after ≥6 months intervention in non-pregnant adults (age ≥ 18 years) with type 1 or type 2 diabetes mellitus. Two reviewers independently extracted data and completed a risk of bias assessment. Appropriate meta-analyses for each outcome from RCTs and pre-post studies were performed. Heterogeneity was assessed using the statistic and Cochran's Q and publication bias assessed using Doi plots. Studies were not pooled to estimate the cost-effectiveness as the cost outcomes were not comparable across trials/studies.
We reviewed 4 RCTs and 12 pre-post studies. The integrated care model of diabetes specialists working with primary care health professionals had a positive impact on HbA1c in both RCTs and pre-post studies and on systolic blood pressure, diastolic blood pressure, total cholesterol and weight in pre-post studies. In the RCTs, interventions reduced HbA1c (-0.10% [-0.15 to -0.05]) (-1.1 mmol/mol [-1.6 to -0.5]), versus control. Pre-post studies demonstrated improvements in HbA1c (-0.77% [-1.12 to -0.42]) (-8.4 mmol/mol [-12.2 to -4.6]), systolic blood pressure (-3.30 mmHg [-5.16 to -1.44]), diastolic blood pressure (-3.61 mmHg [-4.82 to -2.39]), total cholesterol (-0.33 mmol/L [-0.52 to -0.14]) and weight (-2.53 kg [-3.86 to -1.19]). In a pre-post study with no control group only 4% patients experienced hypoglycaemia after one year of intervention compared to baseline.
Integrated interventions with an active endocrinologist involvement can result in modest improvements in HbA1c, blood pressure and weight management. Although the improvements per clinical outcome are modest, there is possible net improvements at a holistic level.
综合糖尿病护理干预措施能显著改善临床结局的证据并不一致。然而，以往的系统评价并未聚焦于内分泌科医生积极参与指导糖尿病管理时的临床效果。
我们检索了截至2021年1月25日以英文发表的EMBASE、Cochrane、MEDLINE、SCOPUS、CINAHL、谷歌学术数据库及灰色文献。纳入的文章包括随机对照试验（RCT）和前后对照研究，这些研究测试了对1型或2型糖尿病非妊娠成人（年龄≥18岁）进行≥6个月干预后对临床结局的有效性。两名研究者独立提取数据并完成偏倚风险评估。对RCT和前后对照研究的每个结局进行了适当的荟萃分析。使用统计量、Cochrane's Q评估异质性，使用Doi图评估发表偏倚。由于各试验/研究的成本结局不可比，因此未合并研究以估计成本效益。
我们回顾了4项RCT和12项前后对照研究。糖尿病专科医生与初级保健健康专业人员合作的综合护理模式在RCT和前后对照研究中对糖化血红蛋白均有积极影响，在前后对照研究中对收缩压、舒张压、总胆固醇和体重也有积极影响。在RCT中，与对照组相比，干预措施使糖化血红蛋白降低了0.10%（-0.15至-0.05）（-1.1 mmol/mol [-1.6至-0.5]）。前后对照研究表明，糖化血红蛋白改善了0.77%（-1.12至-0.42）（-8.4 mmol/mol [-12.2至-4.6]），收缩压改善了3.30 mmHg（-5.16至-1.44），舒张压改善了3.61 mmHg（-4.82至-2.39），总胆固醇改善了0.33 mmol/L（-0.52至-0.14），体重改善了2.53 kg（-3.86至-1.19）。在一项无对照组的前后对照研究中，与基线相比，仅4%的患者在干预一年后出现低血糖。
内分泌科医生积极参与的综合干预措施可使糖化血红蛋白、血压和体重管理得到适度改善。尽管每个临床结局的改善幅度不大，但在整体水平上可能有净改善。
