The global prevalence of type 2 diabetes mellitus (T2DM) continues to rise, posing a significant public health challenge. The shared care model for diabetes has shown substantial clinical value in managing T2DM. However, most research focuses on the short-term effects, while long-term outcomes remain underexplored. Additionally, there is a lack of longitudinal studies examining the relationship between follow-up frequency, app activity levels, and metabolic indicators in T2DM patients.

To assess the impact of regular outpatient follow-up and off-site app activity on the metabolic indicators of T2DM patients within the shared care model, and to identify factors influencing regular follow-up, providing a reference for promoting regular follow-up in T2DM management.

A total of 448 T2DM patients managed in the shared care outpatient clinic of a tertiary hospital in Gansu Province from 2021 to 2023 were included. Based on clinical records, patients were divided into two groups: the regular follow-up group (≥1 visit every 3 months) and the non-regular follow-up group. Health records from the previous 3 years were reviewed, and metabolic indicators (BMI, waist circumference, hip circumference, HbA_1c levels) , complication screening data, and off-site app activity levels were collected. The differences in metabolic indicators between the two follow-up groups and the varying app activity levels were compared, and Logistic regression was performed to identify factors influencing regular follow-up.

Among the 448 patients, 90 (20.1%) were in the regular follow-up group, and 358 (79.9%) were in the non-regular follow-up group. The regular follow-up group exhibited significantly higher app activity levels than the non-regular follow-up group (P<0.05) . Significant time, group, and interaction effects on HbA_1c levels were observed in the regular follow-up group (P<0.05) . After 3 years, the regular follow-up group had higher HbA_1c target achievement rates, and more frequent active screening (P<0.05) . Among patients with high APP activity levels (measured by online communication time, blood glucose monitoring frequency, meal tracking frequency, and app login duration) , significant time and group effects on HbA_1c levels were also observed (P<0.05) , but the interaction between APP activity and time was not significant (P>0.05) . Multivariate Logistic regression analysis revealed that patients with a monthly household income ≥2 000 yuan, those undergoing medication therapy, and those with higher baseline HbA_1c levels were more likely to engage in regular follow-up (P<0.05) .

In the shared care model, regular outpatient follow-up is an effective strategy for controlling blood glucose in T2DM patients. Patients should be encouraged to engage in regular follow-up visits. Furthermore, active participation in the app is closely associated with improved blood glucose control. Promoting online engagement, especially for patients with limited access to healthcare, provides an economically feasible and effective approach to diabetes management.

2型糖尿病（T2DM）的全球患病率持续升高，已成为严峻的公共卫生问题。在应对策略方面，糖尿病共同照护模式展现出较高的临床应用价值，但目前相关研究集中在糖尿病共同照护模式的短期干预效果，长期效果的评估亟待完善，关于随访频率和APP活跃度对患者代谢指标的影响尚缺乏纵向研究支持。

了解糖尿病共同照护模式下门诊规律随访和院外APP活跃度对患者代谢指标的影响，并分析规律随访的影响因素，为逐步引导T2DM患者规律随访提供参考。

以2021—2023年甘肃省某三级甲等医院共同照护门诊管理的448例T2DM患者为研究对象，根据就诊记录将其分为规律随访组（随访频次≥1次/3个月）和非规律随访组。查阅患者近3年健康档案，收集患者的代谢指标[BMI、腰围、臀围、糖化血红蛋白（HbA_1c）水平]、并发症筛查情况、院外APP活跃度。比较是否规律随访患者及不同APP活跃度患者的代谢指标，采用Logistic回归分析患者规律随访的影响因素。

规律随访组患者90例（20.1%），非规律随访组患者358例（79.9%）。规律随访组患者的APP活跃度优于非规律随访组（P<0.05）。规律随访组患者的HbA_1c水平在时间效应、组间效应及交互效应上均表现出显著差异（P<0.05）。规律随访组患者随访3年的HbA_1c达标率高于非规律随访组（P<0.05），主动筛查频次高于非规律随访组（P<0.05）。不同配对血糖监测次数、饮食打卡次数、线上沟通时长、登录APP时长强度患者随访3年的HbA_1c水平显示出显著的时间效应和组间效应（P<0.05），但APP活跃度与时间的交互作用不显著（P>0.05）。多因素Logistic回归分析显示，家庭人均月收入≥2 000元、采用药物治疗、入组时HbA_1c水平较高的T2DM患者具有更高的规律随访倾向（P<0.05）。

在共同照护模式下，门诊规律随访是控制T2DM患者血糖的有效方式，应鼓励患者定期进行门诊随访；同时，患者参与APP的活跃度与血糖控制密不可分，应鼓励患者积极参与线上活动，尤其是对于医疗资源可及性较差的患者，不失为一种经济、有效的控糖方法。