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Diabetes: Disease Management Programs


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.


There is no information for this section.

Summary of Results

Twenty-seven studies qualified for the review.

  • Glycated hemoglobin (GHb) levels: 0.5 percentage point median decrease (Interquartile Interval [IQI]: -1.35% to -0.1%; 19 studies)
  • Monitoring by healthcare providers improved for several diabetes-related conditions:
    • GHb levels: median net increase of 15.6% (IQI: 4% to 39%; 15 studies)
    • Lipid concentrations: median increase of 24.0% (IQI: 21% to 26%; 9 studies)
    • Retinopathy: median increase of 9.0% (IQI: 3% to 20%;15 studies)
    • Urine protein: median increase of 9.7% (IQI: 0% to 44%; 7 studies)
    • Foot lesions and peripheral neuropathy: median increase of 26.5% (IQI: 10.9% to 54%; 9 studies

Summary of Economic Evidence

Two economic studies were included in this review.

  • The first study, conducted in Scotland, reported the average cost for adult patients of an integrated care disease management intervention versus 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 second study was a cost–benefit analysis of preconception plus prenatal care versus prenatal care only for women with established diabetes. No effect size was determined, as this was a modeling study relying on secondary data.



Based on results for interventions in different settings and populations, findings are applicable to adults with either type 1 or type 2 diabetes treated in community clinics and managed care organizations in the U.S. and Europe. It is not clear how well these findings apply to treatment in other settings.


Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified Evidence Gaps

The following outlines evidence gaps for disease and case management interventions to control diabetes.

Even though disease and case management were found effective in the managed care setting for improving glycemic control and provider monitoring of certain important outcomes, several important evidence gaps were identified in this review. One of the most pressing needs is to better define effective interventions. Disease management has multiple component interventions. To make optimal use of resources, however, only the interventions that contribute most to positive outcomes should be implemented, and these need to be defined. Case management interventions are also usually delivered with other interventions, and the effectiveness of these also needs to be defined. Are case management interventions delivered with disease management more effective than case management delivered as a single intervention? Are there specific additional interventions that augment the effectiveness of disease and case management, such as DSME? Additional research questions relating to case management include identifying the optimal intensity (frequency and duration) of patient contact and determining whether professionals other than nurses (e.g., social workers or pharmacists) could function as case managers.

How best to integrate disease and case management interventions into existing healthcare systems also needs to be addressed. What are the strengths and limitations of delivering these interventions as part of primary care or specialty care, or might they best be delivered by contracted organizations and provider networks that are separate from the patient's healthcare delivery system (i.e., the carve-out model)?

Although the existing effectiveness literature examines many important outcomes, research is needed to determine the effect of disease and case management on long-term health and quality of life outcomes, including cardiovascular disease events, renal failure, visual impairment, amputations, and mortality. Further work is also needed to determine the effect of case management on blood pressure, weight, lipid concentrations, and provider screening rates for retinopathy, peripheral neuropathy, and microalbuminuria. In addition, provider and patient satisfaction with these interventions need much more attention from researchers.

As discussed above, the applicability of these data are somewhat limited, leaving numerous important questions unanswered. For example, are disease and case management effective in settings other than HMOs and community clinics, such as academic clinics and independent private practices? Do these interventions work better in some types of delivery systems than others? Are they effective for adolescents with diabetes? How do the cultural, educational, and socioeconomic characteristics of a population affect outcomes? What are the key barriers that providers perceive for disease and case management? How would it be best to obviate them? Do patients perceive any barriers to these interventions?

Numerous deficiencies in the methodologies of these studies were identified. Often there was inadequate descriptive information; studies need to include adequate demographic information (at a minimum, age, gender, race or ethnicity, and type of diabetes), a description of the delivery system infrastructure (automated information systems, prior use of guidelines, resource support, management [medical and non-medical] commitment and support), and details of the intervention (components, 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). In addition, more studies are needed with a concurrent comparison group to control for secular trends in healthcare delivery and patient practices. Finally, studies are needed in which a broad range of providers is recruited.


Study Characteristics

  • Almost all of the included studies evaluated interventions conducted in community clinics or managed care organizations. The 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 the researchers selected specific providers to participate, or the providers volunteered.
  • Studies were conducted predominantly in urban centers in the United States and Europe.
  • The body of evidence on disease management examined either adults with type 2 diabetes or populations with mixed type 1 and 2 (predominantly type 2).