To assess the goal fulfillment in terms of blood glucose, blood pressure, blood lipid, and the composite indicator of these three in patients with diabetes who received intensified treatment at Peking Union Medical College Hospital and regular follow-up for 12 months, analyze the influencing factors, and explore the comprehensive management model for intensive diabetes treatment outpatient services.

This study was a prospective, observational cohort study. The diabetes patients who received long-term regular follow-up at the intensive diabetes treatment outpatient clinic of Peking Union Medical College Hospital from 2012 to 2023 were selected as the research subjects. They were followed up and clinical data were collected at the 1st, 3rd, 6th, 9th, and 12th months of follow-up. The study assessed the goal fulfillment rates in terms of blood glucose, blood pressure, blood lipid, and the composite indicator of these three, with the goals of glycated hemoglobin (HbA1c)<7%, blood pressure<130/80 mmHg, and low-density lipoprotein cholesterol (LDL-C)<2.6 mmol/L. The study also analyzed the impact of factors, including gender, age, type of diabetes, duration of diabetes, body mass index, comorbidities, complications, and treatment regimens, on the outcomes of comprehensive diabetes management.

A total of 232 patients were included in the study, of whom 210 were with type 2 diabetes (90.5%), 13 with type 1 diabetes (5.6%), 5 with latent autoimmune diabetes of the adult (2.2%), 3 with diabetes after total pancreatectomy (1.3%), and 1 with mitochondrial diabetes (0.4%). After 3 months of intensified management, the goal fulfillment rates of blood glucose (67.7% vs. 34.1%, Kappa=0.336, P<0.001), blood pressure (53.4% vs. 37.5%, Kappa=0.159, P=0.001), blood lipid (59.1% vs. 39.2%, Kappa=0.198, P<0.001), and the composite indicator (20.7% vs. 3.0%, Kappa=0.177, P<0.001) were significantly increased. Continued treatment at 6, 9, and 12 months showed stable and sustained increases in the goal fulfillment rates of blood glucose, blood pressure, blood lipid, and the composite indicator. Logistic regression analysis showed that baseline hyperglycemia (P=0.002), disease duration ≥5 years (P<0.001), smoking (P=0.009), alcohol consumption (P=0.038), presence of diabetic complications (P=0.001), combination therapy with oral antidiabetic drugs and insulin (P<0.001), and use of antiplatelet drugs (P=0.037) were risk factors for uncontrolled HbA1c. Baseline hypertension (P<0.001), alcohol consumption (P=0.030), and comorbid dyslipidemia (P=0.028) were risk factors for uncontrolled blood pressure. Baseline uncontrolled LDL-C (P=0.020) and non-use of statins (P<0.001) were risk factors for uncontrolled blood lipid.

Among patients with the long-term follow-up at our intensive diabetes treatment clinic, the goal fulfillment rates of blood glucose, blood lipid, blood pressure, and the composite indicator of these three are relatively higher. However, it is still necessary to improve patient compliance as much as possible, emphasize weight management, and persist on the comprehensive diabetes treatment.

Diabetes; Intensive treatment clinic; Current situation of comprehensive management