Development and Evolution of a Primary Care-Based Diabetes Disease Management Program

H igh-quality diabetes care can reduce diabetes-related complications and improve quality of life. Evidence from randomized trials, including the U.K. Prospective Diabetes Study and the Diabetes Control and Complications Trial, have shown that tight glucose control can decrease microvascular complications.1,2 The Steno 2 trial demonstrated that a multifactorial approach that includes behavioral modification and intensive therapy targeting hyperglycemia, hypertension, and dyslipidemia is effective in reducing progression of microvascular complications among high-risk patients with type 2 diabetes and microalbuminuria.3 Other evidence supports the use of aspirin and statins in middle-aged and older patients with diabetes to prevent heart disease.4 Translating this evidence into practice has proven to be difficult. National data suggest that a large proportion of patients with diabetes continue to receive suboptimal care and have suboptimal outcomes. Only 7% of adults with diabetes in National Health and Nutrition Examination Survey from 1999 to 2000 attained a hemoglobin A1c (A1C) < 7%, blood pressure < 130/80 mmHg, and total cholesterol < 200 mg/dl.5 Attempts to deliver excellent care face a wide variety of barriers at the patient, provider, and system level. For example, competing demands exist for providers' time: patients often have needs they feel are more pressing and demand their providers' attention, whereas providers feel other pressure ranging from time constraints to health maintenance needs. One potential strategy for overcoming the barriers to high-quality care is to implement structured care programs in clinical settings. Effective structured care programs, sometimes referred to as disease management programs, create an “organized system of care that is tailored to multiple problems of chronic illness,” versus the traditional model of care that is designed to address acute illness.6 A recent meta-analysis to assess the impact of these programs on glycemic control in type 2 diabetes found …