To bridge science and patient care in diabetes

Patient-centered diabetes self-management education

Diabetes self-management education (DSME) has been shown to improve health outcomes. Yet, relatively little is known about how DSME has its effects. Literature reviewed from the past 3 years indicates that if DSME is to become more effective interventions need to be theory-based, to increase patient involvement in their care, and to encompass a broader array of evidenced-based outcomes. Outcomes reviewed go beyond knowledge and glycemic control to include prevention of diabetes, quality of life, and reduction of cardiovascular risk. The ability of practitioners and health care systems to implement, adopt, and maintain patient-centered interventions over time is discussed. By linking theory to behavior, and broadening the outcomes examined, advances can continue to be made in closing the gap between the scientific base for the treatment of diabetes, and the care and outcomes patients experience. Further research on patient-centered approaches that promote self-management is seen as critical in closing this gap.

Pharmacological treatment of diabetic patients with cardiovascular complications

Cardiovascular complications are frequently present in insulin-dependent (IDDM) and non-insulin dependent diabetes mellitus (NIDDM) patients and confer a very poor prognosis. In this overview we critically analyse the current literature with regard to the benefits and also the possible harms of the available pharmacological treatment strategies in these patients. To date, insulin is the only hypoglycaemic agent which has been proven both effective and safe in NIDDM patients with cardiovascular complications. Also, several trials indicate that treatment with oral hypoglycaemic agents may confer a substantial risk in such patients. Conventional antihypertensive treatment, including betablockers and diuretics, has been convincingly shown to reduce mortality and morbidity in diabetic nephropathy and in NIDDM patients. However, this may not be the case with newer antihypertensive agents, such as angiotensin-converting enzyme (ACE) inhibitors and calcium channel blockers. Likewise, convincing evidence is lacking that these newer antihypertensive agents provide meaningful clinical benefit when compared to the conventional treatment regarding slower progression of diabetic nephropathy or their impact on lipid and glucose metabolism. Cholesterol lowering therapy with statins and aspirin treatment have also been repeatedly shown to improve the prognosis of diabetic patients with coronary heart disease.

Structured treatment and teaching programme for type 2 diabetic patients on conventional insulin treatment: evaluation of reimbursement policy

The aim of the study was to evaluate the practicability and efficacy of a structured treatment and teaching programme (STTP) for type 2 diabetic outpatients on conventional insulin treatment after introducing remuneration for physicians. Reimbursement policy for the STTP was introduced in the state of Brandenburg, Germany, in July 1993. Between August 1993 and February 1994, 108 physicians and their assistants participated in a postgraduate seminar, which is a prerequisite for remuneration. A standardised interview was performed with 103 physicians and their paramedical personnel. Twenty of the practices who had performed STTP were visited in order to collect data on all the patients who had participated in the programme up to September, 1994. Within the first year already 10% of the target group of physicians participated in the seminars. The seminar and the programme were very well accepted. An improvement of HbA1c levels was observed in patients who had started insulin treatment (n = 35: 9.7 +/- 1.6% of total Hb before, 8.2 +/- 1.3% of total Hb after the programme) and in those who were already being treated with insulin before the STTP (n = 125: 9.6 +/- 2.5% of total Hb before, 8.1 +/- 1.4% of total Hb after the programme). The results of the study demonstrate the efficacy and practicability of an STTP for type 2 diabetic patients on conventional insulin therapy in ambulatory health care.