Abstract: Background　At this stage，the community health service center in China has successively formulated indicators such as high-risk population screening rate and blood glucose control rate to manage community diabetes prevention and treatment.However，it has not managed the high-risk groups，pre-diabetic groups and diabetic patients based on the development stage of diabetes.Objective　To establish a quality control evaluation system of community diabetes management in different disease stages in order to guide the quality control and evaluation of community diabetes management.Methods　A quality control evaluation system of community diabetes management was initially designed through literature review，including basic information of body surface characteristics，life behaviors，biochemical indicators and health interventions.Among them，there were 18 primary indicators and 52 secondary indicators.On this basis，experts in the field of diabetes prevention and treatment were invited to evaluate the importance of each indicator in the quality control evaluation system of community diabetes management from April to June in 2018，and further screening of this indicator system was conducted.Results　A total of 22 consultation questionnaires were distributed and all were recovered with a recovery rate of 100%.The average age of consultants was （39.1±5.2）；their average length of service was （15.7±6.7） years，and their average length of service in the diabetes fields was （13.7±5.9） years.After expert consultation，the quality control evaluation system of community diabetes management was finally constructed as follows：for the quality control evaluation system of diabetes management for high-risk groups，there were four indicator classifications including 13 primary indicators and 40 secondary indicators；for the quality control evaluation system of pre-diabetic groups，there were four indicator classifications including 14 primary indicators and 39 secondary indicators；for the quality control evaluation system of diabetes patients，there were four indicator classifications including 15 primary indicators and 45 secondary indicators.The quality control evaluation indicators of diabetes management for high-risk groups，pre-diabetic groups and diabetic patients were basically the same in body surface characteristics，lifestyle and biochemical indicators，but there were significant differences in health intervention indicators.In the management of high-risk groups of diabetes，health intervention indicators only included file-building，two-way referral，follow-up，blood glucose awareness and diabetes knowledge，and there were blood sugar monitoring rate and（oral） medication guidance in the management of pre-diabetic population while it did not include the blood glucose awareness.In the management of diabetic patients，there were insulin injection guidance and screening for diabetic complications in health intervention indicators.Conclusion　The quality control evaluation system of community diabetes management in different disease stages should be different，which can provide basis for guaranteeing the quality of community diabetes management.

Key words: Diabetes mellitus；Health management；Quality control；Quality assurance, health care；Community health centers

摘要： 背景　现阶段我国社区卫生服务中心虽然陆续制定了诸如高危人群筛查率、血糖控制率等指标对社区糖尿病防治工作进行管理，但却未基于糖尿病的发展阶段对高危人群、前期患者、患者分级进行管理。目的　构建适用于不同疾病阶段的社区糖尿病管理质控评价指标体系，以指导社区糖尿病管理质量控制与评价。方法　采取文献回顾初步设计出一套社区糖尿病管理质控评价指标体系，包括体表特征、生活行为、生化指标和健康干预4类指标，其中一级指标18个，二级指标52个。在此基础上，于2018年4—6月，邀请糖尿病防治领域专家对各指标在社区糖尿病管理质控评价指标体系中的重要程度进行评价，对指标体系进行进一步筛选。结果　共发放咨询问卷22份，全部回收，回收率为100%。咨询专家平均年龄（39.1±5.2）岁，平均工作年限（15.7±6.7）年，专业领域平均工作年限（13.7±5.9）年。经专家咨询，最终构建的社区糖尿病管理质控评价指标体系为：糖尿病高危人群管理质控指标体系包括4个指标分类，13个一级指标，40个二级指标；糖尿病前期人群管理质控指标体系包括4个指标分类，14个一级指标，39个二级指标；糖尿病患者管理质控指标体系包括4个指标分类，15个一级指标，45个二级指标。糖尿病高危人群、糖尿病前期人群和糖尿病患者在体表特征、生活方式、生化指标上的糖尿病管理质控评价指标都基本一致，只在健康干预类指标出现较大差异：糖尿病高危人群管理中，健康干预类指标仅包括建档、双向转诊、随访、血糖知晓和糖尿病知识；糖尿病前期人群管理中，健康干预类指标相较于高危人群少了血糖知晓，多了血糖监测率、（口服药）用药指导；糖尿病患者管理中，健康干预类指标相较于前期患者多了胰岛素注射和糖尿病并发症筛查。结论　不同疾病发展阶段的社区糖尿病管理质控评价指标体系应有所区别，可为保障社区糖尿病管理质量提供依据。

关键词: 糖尿病；健康管理；质量控制；质量保证, 卫生保健；社区卫生中心