A seven-year study on an integrated hospital-community diabetes management program in Chinese patients with diabetes

Abstract Aims To assess whether an integrated hospital-community diabetes management program could improve major cardiovascular risk factor control among patients with diabetes in real-world clinical settings. Methods 985 adults with diabetes in the Shanghai Taopu community health service center were enrolled at baseline and 907 subjects completed the follow-up. The follow-up levels of the metabolic profiles were assessed by their averages during the follow up period. Results After a mean 7-year follow-up period, heamoglobin A1c, systolic and diastolic blood pressure levels decreased by 0.6%, 5.7 mmHg, and 1.5 mmHg, respectively (all P  Conclusions This long-term program has increased the proportions of attaining major cardiovascular risk factors control goals and diabetic chronic complication screening rates among patients with diabetes.