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Diabetes: Disease Management Programs

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What the Task Force Found

About The Systematic Review

The Task Force finding is based on evidence from a systematic review of 27 studies (search period through December 2000). The review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to diabetes prevention and control.

Context

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Summary of Results

More details about study results are available in the published evidence review [PDF - 784 kB].

The review included 27 studies, which provided the following results:

  • Glycated hemoglobin (GHb) levels: 0.5 percentage point median decrease (19 studies)
  • Monitoring by healthcare providers improved for several diabetes-related conditions:
    • GHb levels: median increase of 15.6% (15 studies)
    • Lipid concentrations: median increase of 24.0% (9 studies)
    • Retinopathy: median increase of 9.0% (15 studies)
    • Urine protein: median increase of 9.7% (7 studies)
    • Foot lesions and peripheral neuropathy: median increase of 26.5% (9 studies)

Summary of Economic Evidence

More details about study results are available in the published evidence review [PDF - 784 kB].

Two economic studies were included in the review.

  • A study from Scotland reported the average cost for adult patients of an integrated care disease management intervention compared with traditional hospital clinic care.
    • Annual average adjusted costs were $143 to $185 for integrated care and $101 for traditional care, resulting in a higher annual average cost for the intervention of $42 to $84.
    • After two years, no significant difference was seen between the two groups for GHb, body mass index, creatinine, or blood pressure.
    • Integrated care patients had higher annual rates compared with the traditional care group for routine diabetes care visits (5.3 versus 4.8) and screening and monitoring of GHb (4.5 versus 1.3), blood pressure (4.2 versus 1.2), and visual acuity (2.6 versus 0.7).
  • The other study was a cost–benefit analysis of preconception plus prenatal care versus prenatal care only for women with established diabetes. This modeling study relied on secondary data; no effect size was determined.

Applicability

Findings are applicable to adults with type 1 or type 2 diabetes who are treated in community clinics and managed care organizations in the United States and Europe. It is not clear how well these findings apply to treatment in other settings.

Evidence Gaps

Additional research and evaluation are needed in these areas to fill existing gaps in the evidence base. (What are evidence gaps?)

  • What components are needed to make a disease management program effective?
  • Are there additional interventions that add to the effectiveness of disease management, such as self-management education?
  • How should disease management programs be integrated into existing healthcare systems?
  • What are the strengths and limitations of delivering programs as part of primary care or specialty care?
  • What are program effects on long-term health and quality-of-life outcomes, including cardiovascular disease events, renal failure, visual impairment, amputations, and death?
  • How satisfied are providers and patients with these programs?
  • Are disease management programs effective in settings other than HMOs and community clinics, such as academic clinics and independent private practices?
  • Do interventions work better in some types of delivery systems than others?
  • How does program effectiveness vary by patient’s age, gender, race, or ethnicity?
  • How do the cultural, educational, and socioeconomic characteristics of a population affect outcomes?
  • What key barriers do providers or patients see? What is the best way to eliminate them?
  • How do the following affect program effectiveness: delivery system infrastructure (automated information systems, prior use of guidelines, resource support, management [medical and non-medical] commitment and support), frequency and duration of patient contact, who delivered the intervention, whether and which clinical practice guidelines were used, and degree and type of interface with primary care?
  • What are the impacts of secular trends in healthcare delivery and patient practices on program effectiveness?
  • What types of providers should be involved in programs?

Study Characteristics

  • Almost all evaluated programs were carried out in community clinics or managed care organizations. Managed care organizations included network- or primary care–based models and staff or group model HMOs.
  • Studies generally involved the entire population of providers in a facility, although in some studies researchers selected specific providers or recruited providers to volunteer.
  • Studies came from mostly urban centers in the United States and Europe.
  • Study populations were either adults with type 2 diabetes or adults with type 1 or 2 diabetes (predominantly type 2).

Publications