探讨在北京大学第一医院接受共同照护持续管理超过1年的2型糖尿病患者中，不同病程患者的糖化血红蛋白（HbA1c）达标率及疾病自我管理能力的变化趋势。

以2016年10月至2018年6月在共同照护门诊规律就诊1年以上的2型糖尿病患者做为研究对象，收集其一般资料。按照季度复诊诊次在V1（初诊）、V2（1个季度）、V3（2个季度）、V4（3个季度）、V5（1年）收集HbA1c及降糖药物日花费，分别在患者初诊及随访1年时，使用糖尿病自我管理行为量表6（SDSCA-6）评价其疾病自我管理能力。依据病程将患者分为A（0~2.5年）、B（>2.5~5.0年）、C（>5~10年）、D（>10~15年）、E（>15年）组，分析不同病程组间、组内在不同复诊诊次HbA1c达标率及各项自我管理能力的变化。

符合入选标准、完成数据收集及接受初诊、随访1年的自我管理能力评估的2型糖尿病患者共计232例，其中A组63例，B组14例，C组48例，D组51例，E组56例；随病程延长，随访1年时HbA1c达标率由83.3%降低至32.0%；除A组5次随访间HbA1c达标率差异有统计学意义（P<0.05）外，其余病程组5次随访期间HbA1c达标率差异均无统计学意义（P均>0.05）。与同组V1时相比，D、E组在V5时降糖药物日花费显著增加［D组：15.2（8.2，28.0）元 vs 14.8（9.8，24.1）元，Z=-2.253，P=0.024；E组：22.1（14.5，32.5）元 vs 18.5（10.8，27.8）元，Z=-3.036，P=0.002］。SDSCA-6得分方面，与初诊相比，V5时A组患者疾病自我管理能力在运动［4（2，7）分 vs 6（3，7）分，P=0.004］、遵医嘱监测血糖［2（0.75，3）分 vs 3（0，7）分，P=0.028］方面得分显著降低；C组在运动［6（2.25，7）分 vs 3（1，7）分，P=0.007］、自测血糖［3（1，6.75）分 vs 2（0，4）分，P=0.016］、足部检查［6（1.25，7） vs 0（0，7），P<0.001］方面，D组在遵医嘱测血糖［3（1，5.75）分 vs 1（0，5）分，P=0.010］、足部检查［5（0，7）分 vs 1（0，7）分，P=0.009］方面，E组在遵医嘱测血糖［4（1，7）分 vs 1（0，5）分，P=0.009］方面得分显著提高。

2型糖尿病患者HbA1c及其达标率随病程延长显著降低。不同病程患者在HbA1c达标维持过程中，自我管理能力及药物花费的变化具有较大差异。为了改善个体化管理质量、应对病程延长带来的代谢指标控制难度增加的问题，可能需要更多地关注病程早期患者的自我管理能力。

To investigate the hemoglobin Alc (HbA1c) achievement rate and self-management ability of type 2 diabetes patients of different clinical stages receiving Diabetes Shared Care at Peking University First Hospital.

This study summarized the data of type 2 diabetes patients who were under regular follow-ups for Diabetes Shared Care at Peking University First Hospital from October 2016 to June 2018. HbA1c levels and the expenditure of anti-diabetic drugs were collected at the first visit (V1), second visit (V2, 3 months after V1), third visit (V3, 6 months after V1), fourth visit (V4, 9 months after V1), and fifth visit (V5, 12 months after V1). The summary of diabetes self-care activities-6 (SDSCA-60) for the evaluation of self-management ability was collected at V1 and V5. Also, the patients were divided into five groups in accordance with the duration of diabetes: group A, 0-2.5 years; group B, >2.5-5 years; group C, >5-10 years; group D, >10-15 years; group E, >15 years. Chi-square test was performed to evaluate the HbA1c achievement rate in each group.

A total of 232 patients who were under regular follow-ups and completed data collection were enrolled in the study, including 63 patients in group A, 14 in group B, 48 in group C, 51 in group D, and 56 in group E. HbA1c achievement rate gradually decreased along with the increase in diabetic duration (83.3% in group A to 32.0% in group E at V5). Medical expenditure in groups D [15.2 (8.2, 28.0) yuan vs 14.8 (9.8, 24.1) yuan, Z=-2.253, P=0.024] and E [22.1 (14.5, 32.5) yuan vs 18.5 (10.8, 27.8) yuan, Z=-3.036, P=0.002] was higher at V5 compared to V1. Self-management ability in group A decreased with regard to exercise [4 (2, 7) vs 6 (3, 7), P=0.004] and glucose monitoring according to prescription [2 (0.75, 3) vs 3(0, 7), P=0.028]. Self-management ability increased in group C in exercise [6 (2.25, 7) vs 3 (1, 7), P=0.007], glucose monitoring [3 (1, 6.75) vs 2 (0, 4), P=0.016], and foot examination [6 (1.25, 7) vs 0 (0, 7), P<0.001], in group D in glucose monitoring [3 (1, 5.75) vs 1 (0, 5), P=0.010] and foot examination [5 (0, 7) vs 1 (0, 7), P=0.009], and in group E in glucose monitoring [4 (1, 7) vs 1 (0, 5), P=0.009].

HbA1c achievement rate decreases along with the duration of diabetes. During the maintenance of glucose control among patients with different disease durations, the changes of self-management ability and drug expenditure are quite different. It is critical to pay more attention to self-management ability in the early stage of diabetes to overcome the difficulty along with longer diabetes duration.