Diabetes has become a significant global public health issue. In China, the prevalence of diabetes has been steadily increasing, placing a substantial burden on healthcare resources. The primary healthcare system plays a crucial role in diabetes management, yet there are still deficiencies in improving the quality of diabetes management services and achieving adequate blood glucose control.

This policy brief aims to explore and analyze evidence-based quality improvement interventions for diabetes management in primary healthcare settings, providing practical recommendations for policy and practice.

During July to December 2024, a systematic search was conducted using the PubMed, Epistemonikos, and Health System Evidence databases to identify relevant systematic reviews published in the past 10 years. The focus was on quality improvement interventions for type 2 diabetes management in primary healthcare systems, with an additional analysis of their effectiveness in China.

A total of 33 international systematic reviews and 22 original studies from China were included. The interventions were categorized using the Chronic Care Model (CCM), which identifies six key strategies: (1) high-quality healthcare service organization; (2) community resource linkages; (3) self-management support; (4) delivery system design; (5) decision support; and (6) information systems. Regarding the primary health outcome—blood glucose control—two types of interventions, including high-quality integrated interventions focused on service organization optimization and self-management support, showed positive effects in all studies. The evaluation of other interventions was inconsistent or lacked sufficient evidence. Studies conducted in China validated the positive effects of four intervention strategies on blood glucose control. However, evidence for the effectiveness of "enhancing community resource linkages" and "strengthening decision support" remains insufficient in China.

This policy brief summarizes effective interventions for diabetes management in primary healthcare systems, based on the best evidence available and the results from their implementation in China. It recommends prioritizing two key strategies: fostering a culture of quality improvement across the entire system and implementing a comprehensive chronic disease management model, while in areas where a full system-wide approach cannot be implemented, prioritizing interventions that support patient or community self-management. Additionally, the brief emphasizes expanding multi-sector collaboration and exploring more practices to strengthen community resource linkages, while also providing primary healthcare personnel with more direct and actionable guidelines.

糖尿病已成为全球重要的公共卫生问题，中国糖尿病患病率逐年上升，成为卫生体系资源的重要消耗者。基层医疗卫生体系在糖尿病管理中发挥着关键作用，但目前我国基层卫生服务在糖尿病管理的质量提升和血糖控制方面仍存在不足。

制定政策简报，探讨应用于基层医疗服务提供者并有实证依据支持的2型糖尿病管理服务质量改进干预措施，为政策和实践提供参考。

2024年7—12月通过系统检索PubMed、Epistemonikos和Health System Evidence数据库，筛选近10年的相关系统评价文献，纳入国际已应用的、针对基层医疗卫生机构2型糖尿病管理的质量改进措施，并对应分析其在中国应用的效果。

共纳入33项符合研究质量标准的系统评价及22项中国地区已经应用的原始研究。干预内容分析中使用慢性病管理模式将所有干预分为6个关键策略：以高质量为导向的卫生服务组织综合干预、社区资源链接、自我管理支持、服务提供方式设计、决策支持、信息系统。在糖尿病管理最直接健康结局指标"血糖控制水平"上，两类干预的研究均显示促进作用，包括：以提高质量为导向"优化服务组织"的综合干预、"提供自我管理支持"；其他干预的评价效果存在不一致或者缺乏证据等问题。中国研究应用并验证了4类干预策略对血糖控制的正向作用，但"加强社区资源链接""增强决策支持"这两类干预策略在中国还欠缺证据。

该政策简报总结了基层医疗卫生体系在糖尿病管理中的有效干预策略，结合当前最高质量证据的评价结果和我国应用的效果，建议重点推广和应用两类干预策略：（1）以高质量为导向、全系统综合慢性病管理模式；（2）在无法全系统启动整合慢性病管理模式的地区可优先推行患者自我管理支持的相关干预。此外，也建议逐步拓展多部门合作、探索更多"加强社区资源链接"领域的做法；同时，需要对基层医疗卫生机构的医务人员提供更多直接的、可操作的工作指南。