While the effectiveness of generalist-specialist collaborative care in chronic care management has been well-documented in high-income countries, evidence from China is limited.

To systematically evaluate the effect of multidisciplinary team-based care, collaboratively provided by hospital-based specialists and community-based generalists, on hypertension and diabetic outcomes in primary care settings in China.

In October 2024, a comprehensive literature search was conducted across PubMed, Cochrane Library, Web of Science, Embase, CNKI, Wanfang Data Knowledge Service Platform, VIP Database, SinoMed, covering publications from 2011-07-06 to 2024-10-14. The control group received standard health management services, while the intervention group received the collaborative model in addition to standard care. Two independent researchers performed literature screening, quality assessment, and data extraction, with consensus reached for any discrepancies. Meta-analysis was conducted using RevMan 5.4.1 and Stata 17.0 software.

Seventeen randomized controlled trials involving 21 591 participants were included, with 13 819 in the intervention group and 7 772 in the control group. Meta-analysis showed that the generalist-specialist collaborative care significantly improved outcomes for diabetic patients, including reduced glycated hemoglobin (MD=-0.72, 95%CI=-0.96 to -0.48, P<0.001) , fasting blood glucose (MD=-0.84, 95%CI=-1.04 to -0.65, P<0.001) , and 2-hour postprandial blood glucose (MD=-1.12, 95%CI=-1.52 to -0.72, P<0.001) . For hypertensive patients, the model significantly reduced systolic blood pressure (MD=-6.49, 95%CI=-7.53 to -5.44, P<0.001) and diastolic blood pressure (MD=-6.00, 95%CI=-8.89 to -3.12, P<0.001) . Subgroup analyses revealed significant differences in intervention effects across gender, age, and intervention duration. Egger's test indicated potential publication bias for glycated hemoglobin (P=0.003) and fasting blood glucose (P=0.002) .

The collaborative service model between generalist and specialists significantly improves blood pressure and blood glucose indicators in patients with hypertension and diabetes at the primary care level, and should be promoted as a key measure in chronic disease management within national basic public health services. High-quality and large community trials are needed to identify strategies to enhance an in-depth collaboration between hospital-based specialists and community-based generalists, thereby further improving population health and enhancing the efficiency of healthcare utilization.

国际上，多学科团队协作的服务模式在改善慢性病患者健康结局方面已有充分且严谨的证据支持。在中国，虽然以全科和专科为核心的团队协作模式探索逐渐增多，但仍缺乏系统的评价与分析。

系统评价中国情景下全-专协同服务模式对高血压和糖尿病患者的健康影响。

于2024年10月，计算机检索PubMed、Cochrane Library、Web of Science、Embase、中国知网、万方数据知识服务平台、维普网、中华医学期刊全文数据库，筛选基于全-专协同服务模式管理高血压和糖尿病患者的随机对照试验，其中对照组采用常规健康管理服务，干预组在对照组基础上采用全-专协同服务模式。检索时限为2011-07-06至2024-10-14。文献筛选、质量评价和数据提取由2名研究人员独立完成。采用RevMan 5.4.1和Stata 17.0软件进行Meta分析。

最终纳入17篇文献，共有受试者21 591例，其中干预组13 819例，对照组7 772例。Meta分析结果显示，全-专协同服务模式更能降低糖尿病患者的糖化血红蛋白（MD=-0.72，95%CI=-0.96~-0.48，P<0.001）、空腹血糖（MD=-0.84，95%CI=-1.04~-0.65，P<0.001）、餐后2 h血糖（MD=-1.12，95%CI=-1.52~-0.72，P<0.001），以及高血压患者的收缩压（MD=-6.49，95%CI=-7.53~-5.44，P<0.001）和舒张压（MD=-6.00，95%CI=-8.89~-3.12，P<0.001）。亚组分析结果显示，全-专协同服务模式干预效果在不同性别、年龄、干预周期的患者中存在明显差异。Egger's检验显示，糖化血红蛋白（P=0.003）和空腹血糖（P=0.002）可能存在发表偏倚。

全-专协同服务模式对改善基层在管高血压患者的血压水平和糖尿病患者的血糖水平具有显著作用，应作为国家基本公共卫生服务中两病健康管理的重要手段加以推广实施。目前基于全-专协同服务模式管理高血压患者的研究相对较少，仍需开展更多高质量、多中心、大样本的社区试验，以进一步提升基层防病治病和慢性病健康管理能力。