(2003; 211 pages)
Diabetes is a typical chronic disease that demonstrates the need for integrated and multifaceted approaches to achieve good control. Almost any intervention designed to improve metabolic control in diabetic patients, or to delay the onset of complications does so by supporting patients in developing appropriate self-management behaviours. Interventions to enhance adherence in patients with diabetes benefit from a comprehensive and multifactorial approach to providing better control of the disease.
For example, a systematic review by Renders and colleagues (1), of interventions to improve the management of diabetes mellitus in primary care, conducted in outpatient and community settings, analysed 41 heterogeneous studies of multifaceted intervention strategies. Some of these studies were targeted at health professionals, others at the organization of care, but most of them targeted both. In 15 studies, patient education was added to the professional and organizational interventions. The reviewers concluded that multifaceted professional interventions can enhance the performance of health professionals in managing diabetic patients. Organizational interventions that improve regular prompted recall and review of patients can also improve diabetes management. In addition, the inclusion of patient-oriented interventions can lead to improved health outcomes for the patients. Nurses can play an important role in patient-oriented interventions, through patient education and facilitating adherence to treatment.
A recent meta-analysis has shown that education about self-management improves glycaemic levels at immediate follow-up, and increased contact time increases this effect. However, the benefit declines 1-3 months after the intervention ceases, suggesting that learned behaviours change over time (2), and that some additional interventions are needed for maintaining them.
In a study in Switzerland, Gozzoli et al. estimated the impact of several alternative interventions for improving the control of complications of diabetes (3). They concluded that the implementation of multifactorial interventions, including improved control of cardiovascular risk factors, combined with early diagnosis and treatment of complications of diabetes, could save both costs and lives.
Nurse case-management (4-6), disease management (7,8) and population-based management (9) have all resulted in better adherence to recommended standards of care, sometimes with impressive clinical and economic outcomes. Moreover, the Chronic Care Model (CCM), a systematic approach to improving the quality of care for persons with chronic diseases, has shown promising results (10,11).
Positive results have also been reported from the United States by the Diabetes Roadmap of Group Health Cooperative of Puget Sound (GHC), an HMO serving about 400 000 people in western Washington state, which uses the strategy of population-based management of care to improve care and outcomes for its 13 000 diabetic patients (9). Population-based care uses guidelines, and epidemiological data and techniques to plan, organize, deliver and monitor care in specific clinical sub-populations such as patients with diabetes. This support programme is aimed at helping primary care teams to improve their ability to deliver population-based diabetes care. Based on an integrated CCM, the programme includes an on-line registry of diabetic patients, evidence-based guidelines for routine diabetes care, improved support for patient self-management and practice re-design including group visits. Also, members of a decentralized diabetes education team see patients jointly. Preliminary outcomes show that retinal screening rates have increased from 56% to 70%, renal screening rates from 18% to 68%, foot examination rates from 18% to 82% and patients being tested for glycosylated haemoglobin from 72% to 92%. The cost of care for the entire population of diabetic patients has decreased by 11%.
Most studies that reported cost-savings used a systematic approach to disease management (8,12). More research is needed to assess the cost-effectiveness of interventions aimed at improving adherence rates (13).