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Exp Clin Endocrinol Diabetes 2006; 114(1): 18-27
DOI: 10.1055/s-2005-873079
Article

J. A. Barth Verlag in Georg Thieme Verlag KG Stuttgart · New York

Structured Diabetes Therapy and Education Improves the Outcome of Patients with Insulin Treated Diabetes Mellitus

The 10 Year Follow-Up of a Prospective, Population-Based Survey on the Quality of Diabetes Care (The JEVIN Trial)R. Schiel1 , U. Voigt2 , I. S. Ross3 , A. Braun1 , A. Rillig1 , W. Hunger-Dathe1 , G. Stein1 , U. A. Müller1
  • 1Department of Internal Medicine III, University of Jena Medical School, Jena, Germany
  • 2Department of Ophthalmology, University of Jena Medical School, Jena, Germany
  • 3Department of Clinical Biochemistry, University of Aberdeen Medical School, Aberdeen, United Kingdom
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Publication History

Received: March 24, 2004 First decision: July 21, 2004

Accepted: December 7, 2005

Publication Date:
01 February 2006 (online)

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Abstract

Aims/hypothesis: JEVIN (Jena's St. Vincent Trial) is a prospective, 10 year follow-up, population-based survey of all insulin treated patients with type 1 and type 2 diabetes mellitus aged 16 to 60 years and living in the city of Jena (100 000 inhabitants), Thuringia, Germany. It aims to show the effects of implementation of the St. Vincent Declaration and to evaluate the effect of recent changes in the health care system and new treatment strategies. Patients and Methods: 190 patients (83 % of the target population), 244 patients (90 %) and 261 patients (90 %) were studied in 1989/90, 1994/95 and 1999/2000, respectively. Results: Up to 1994/95, the HbA1c of patients with type 1 diabetes mellitus increased (1994/95: 8.50 ± 1.80 % versus 1989/90: 7.83 ± 1.60 %, p = 0.002). For patients with type 2 diabetes mellitus, it remained constant (9.01 ± 2.06 % versus 9.17 ± 1.60 %, n. s.). During the period from 1994/95 to 1999/2000, there was a substantial improvement in the relative HbA1c of both, patients with type 1 (7.62 ± 1.55 %, p < 0.0001), and with type 2 diabetes (7.57 ± 1.29 %, p < 0.0001). Up to 1999/2000, 87.7 % of the patients with type 1 (1989/90: 0 %, 1994/95: 73.2 %) and 96.6 % of the patients with type 2 diabetes (1989/90: 0 %, 1994/95: 89.7 %) participated in TTP's. The incidence of acute and the prevalence of long-term complications remained constant. Conclusions: Results of the population-based, prospective trial to optimise patients' quality of diabetic control suggest: For patients with insulin treated type 2 diabetes mellitus, excellent treatment can be available by primary care physicians interested, educated and highly engaged in diabetes therapy. Moreover, structured diabetes therapy consisting of treatment and teaching programmes, regular self-monitoring, patients' insulin dose adjustment and patients' empowerment, should be offered to all patients with diabetes mellitus.

Key words

Type 1 diabetes mellitus - type 2 diabetes mellitus - population-based trial - HbA1c - quality of diabetes care - insulin therapy - structured treatment and teaching programmes - primary health care

References

  • 1 Berger M, Grüßer M, Jörgens V, Kronsbein P, Mühlhauser I, Scholz V, Venhaus A, Standl E. Behandlungs- und Schulungsprogramm für Typ-II-Diabetiker, die Insulin spritzen. Cologne, Germany; Deutscher Ärzte-Verlag 1994
    Google Scholar
  • 2 Berger (ed) M. Diabetes mellitus. 2nd ed. Munich, Germany; Urban & Fischer 2000
    Google Scholar
  • 3 Berger M, Jörgens V, Flatten G. Health care for patients with non-insulin-dependent diabetes mellitus. The German experience.  Ann Intern Med. 1996;  124 153-155
    PubMedGoogle Scholar
  • 4 Berger M, Mühlhauser I. Implementation of intensified insulin therapy: A European perspective.  Diab Med. 1995;  12 201-208
    CrossrefPubMedGoogle Scholar
  • 5 Bruno G, Bargero G, Vuolo A, Pisu E, Pagano G. A population-based prevalence survey of known diabetes mellitus in nothern Italy based upon multiple independent sources of ascertainment.  Diabetologia. 1992;  35 851-856
    CrossrefPubMedGoogle Scholar
  • 6 Bruno G, Cavallo-Perin P, Bargero G, Borra M, D'Errico N, Pagano G. Glycaemic control and cardiovascular risk factors in type 2 diabetes: A population-based study.  Diab Med. 1998;  15 304-307
    CrossrefPubMedGoogle Scholar
  • 7 Bruns W. Behandlung mit Diät. Bibergeil H Diabetes Mellitus. Jena, Germany; VEB Gustav Fischer Verlag 1989: 254-315
    Google Scholar
  • 8 Chantelau E. Diät bei Diabetes mellitus. Berger M Diabetes Mellitus. Munich, Germany; Urban & Schwarzenberg Verlag 1995: 126-158
    Google Scholar
  • 9 Colhoun H M, Dong W, Barakat M T, Mather H M, Poulter N R. The scope for cardiovascular disease risk factor intervention among people with diabetes mellitus in England: A population-based analysis from the health surveys in England 1991 - 1994.  Diab Med. 1999;  16 35-40
    CrossrefPubMedGoogle Scholar
  • 10 [no authors listed] . Early treatment diabetic retinopathy study group.  Ophthalmology. 1991;  98 (Suppl 5)
    PubMedGoogle Scholar
  • 11 Feste C. A practical look at patient empowerment.  Diab Care. 1992;  15 922-925
    PubMedGoogle Scholar
  • 12 Gries F A, Piwernetz (eds) K. St. Vincent Register 1994. Beiträge zur Umsetzung der St.‐Vincent-Deklaration in Deutschland. Mainz, Germany; Verlag Kirchheim 1994
    Google Scholar
  • 13 Grüßer M, Jörgens V. Diabetes in der Praxis. Fortbildungsveranstaltung „Diabetes melitus“ für Kassenärzte. Projekt des Bundesministeriums für Gesundheit und des Zentralinstitutes für kassenärztliche Versorgung in der Bundesrepublik Deutschland in Zusammenarbeit mit der Deutschen Diabetesgesellschaft e.V., der Kassenärztlichen Bundesvereinigung und den Kassenärztlichen Vereinigungen der Länder. Cologne, Germany; Deutscher Ärzte-Verlag 1992
    Google Scholar
  • 14 Grüßer M, Hartmann P, Jörgens V. Behandlungs-und Schulungsprogramm für Typ-1-Diabetiker. Mainz, Germany; Verlag Kirchheim 1996
    Google Scholar
  • 15 Grüßer M, Jörgens V, Berger M. Vor dem Essen Insulin. Für die flexible Behandlung des Typ-2-Diabetes mit Normalinsulin. Mainz, Germany; Kirchheim-Verlag 1999
    Google Scholar
  • 16 Guidelines Subcommittee . 1999 World Health Organization - International society of hypertension guidelines for the management of hypertension.  J Hyperten. 1999;  17 151-183
    PubMedGoogle Scholar
  • 17 Head J, Fuller J H. International variation in mortality among diabetic patients: The WHO multinational study of vascular disease in diabetics.  Diabetologia. 1990;  33 477-481
    CrossrefPubMedGoogle Scholar
  • 18 Jackson J L. The German health system. Lessons for reform in the United States.  Arch Int Med. 1997;  157 155-160
    PubMedGoogle Scholar
  • 19 Joergens V, Gruesser M. Three years' experience after national introduction of teaching programs for type II diabetic patients in Germany: How to train general practitioners.  Patient Edu Counseling. 1995;  26 195-202
    PubMedGoogle Scholar
  • 20 Kassenärztliche Vereinigung Thüringen .Modellversuch Vereinbarung über eine strukturierte und qualitätsgesicherte ambulante Versorgung von Patienten mit Diabetes mellitus zwischen der Kassenärztlichen Vereinigung Thüringen und der AOK Thüringen. Anlage 3, RS III/1998. Erfurt, Germany; KV Thüringen 1998
    Google Scholar
  • 21 King H, Gruber W, Lander (eds) T. Report of a WHO Meeting. Implementing National Diabetes Programmes. WHO Division of Noncommunicable Diseases. Geneva, Switzerland; WHO 1995
    Google Scholar
  • 22 Liniger C, Albeanu A, Bloise D, Assal J P. The tuning fork revisited.  Diab Med. 1990;  7 859-864
    PubMedGoogle Scholar
  • 23 Mehnert H. Ernährungstherapie. Mehnert H, Schöffling K, Standl E, Usadel KH Diabetologie in Klinik und Praxis. Stuttgart, Germany; Georg Thieme Verlag 1994: 162-210
    Google Scholar
  • 24 Mühlhauser I, Jörgens V, Berger M. Bicentric evaluation of a teaching programme for type I diabetic patients.  Diabetologia. 1983;  25 470-476
    PubMedGoogle Scholar
  • 25 Mühlhauser I, Bruckner I, Berger M, Cheta D, Jörgens V, Ionescu-Tirgoviste C, Scholz V, Mincu I. Evaluation of an intensified insulin treatment and teaching programme as routine management of type 1 (insulin-dependent) diabetes. The Bucharest-Düsseldorf Study.  Diabetologia. 1987;  30 681-690
    CrossrefPubMedGoogle Scholar
  • 26 Mühlhauser I, Sulzer M, Berger M. Quality assessment of diabetes care according to the recommendations of the St. Vincent Declaration: a population-based study in a rural area of Austria.  Diabetologia. 1992;  35 429-435
    PubMedGoogle Scholar
  • 27 Mühlhauser I, Overmann H, Bender R, Bott U, Jörgens V, Trautner Ch, Siegrist J, Berger M. Social status and the quality of care for adult people with type I (insulin-dependent) diabetes mellitus - a population-based study.  Diabetologia. 1998;  41 1139-1150
    CrossrefPubMedGoogle Scholar
  • 28 Müller U A, Chantelau E, Ross I S, Klinger H. Wurden in der ehemaligen DDR die Diabetiker nicht nur „gut verwaltet“, sondern auch „gut behandelt“?.  Z gesamte Inn Med. 1993;  13-17
    PubMedGoogle Scholar
  • 29 Müller U A, Ross I S, Klinger H, Geisenheiner S, Chantelau E A. Quality of centralized diabetes care: a population-based study in the German Democratic Republic 1989 - 1990.  Acta Diabetol. 1993;  30 166-172
    CrossrefPubMedGoogle Scholar
  • 30 Müller U A, Müller R, Starrach A, Hunger-Dathe W, Schiel R, Jörgens V, Grüßer M. Should insulin therapy in type 2 diabetic patients be started on an out- or inpatient basis? Results of a prospective controlled trial using the same treatment and teaching programme in ambulatory care and a university hospital.  Diab Metabol. 1998;  24 251-255
    PubMedGoogle Scholar
  • 31 Müller U A, Femerling M, Reinauer K M, Risse A, Voss M, Jörgens V, Berger M, Mühlhauser I, for the A SD. Intensified treatment and education of type-1 diabetes mellitus as clinical routine: A nation-wide quality-circle experience in Germany.  Diab Care. 1999;  22 B29-B34
    PubMedGoogle Scholar
  • 32 New J P, Hollis S, Campbell F, McDowell D, Burns E, Dornan T L, Young R J. Measuring clinical performance and outcomes from diabetes information systems: An observational study.  Diabetologia. 2000;  43 836-843
    CrossrefPubMedGoogle Scholar
  • 33 Ohkubo Y, Kishikawa H, Araki E, Miyata T, Isami S, Motoyoshi S, Kojima Y, Furuyoshi N, Shichiri M. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study.  Diab Res Clin Pract. 1995;  28 103-117
    CrossrefPubMedGoogle Scholar
  • 34 Panzram G. Mortality and survival in type 2 (non-insulin-dependent) diabetes mellitus.  Diabetologia. 1987;  30 123-131
    CrossrefPubMedGoogle Scholar
  • 35 Pi-Sunyer F X. The obesity epidemic: Pathophysiology and consequences of obesity.  Obesity Res. 2002;  10 97S-104S
    CrossrefPubMedGoogle Scholar
  • 36 Reichard P, Nilsson B Y, Rosenqvist U. The effect of long-term intensified insulin treatment on the development of microvascular complications of diabetes mellitus.  N Engl J Med. 1993;  329 304-309
    CrossrefPubMedGoogle Scholar
  • 37 Rillig A, Müller U A, Braun A, Leppert K, Schiel R. Quality of life of patients with type 1 and insulin treated type 2 diabetes mellitus in a selection free population. Results of a prospective trial 1989/90 to 1999/2000 (JEVIN).  Diab Stoffw. 2003;  12 95-104
    PubMedGoogle Scholar
  • 38 Sawicki P T. for the Diabetes Treatment and Teaching Programmes Working Group . Stabilization of glomerular filtration rate over 2 years in patients with diabetic nephropathy under intensified therapy regimes.  Nephrol Dial Transplant. 1997;  12 1890-1899
    PubMedGoogle Scholar
  • 39 Schiel R, Müller U A, Sprott H, Schmelzer A, Mertes B, Hunger-Dathe W, Ross I S. The JEVIN-trial: A population-based survey on the quality of diabetes care in Germany - 1994/95 compared to 1989/90.  Diabetologia. 1997;  40 1350-1357
    CrossrefPubMedGoogle Scholar
  • 40 Schiel R, Müller U A, Ulbrich S. Long-term efficacy of a 5-day structured teaching and treatment programme (5-DTTP) for intensified insulin therapy (ICT) and risk for severe hypoglycemia.  Diab Res Clin Pract. 1997;  35 41-48
    CrossrefPubMedGoogle Scholar
  • 41 Schiel R, Hoffmann A, Müller U A. Behandlungsqualität bei Patienten mit Diabetes mellitus in einem ländlichen Gebiet Deutschlands. Ergebnisse einer Populationsuntersuchung - Die ZEUVIN-Studie.  Med Klinik. 1999;  94 127-132
    CrossrefPubMedGoogle Scholar
  • 42 Schulz B, Bibergeil H, Rybka J, Koev D. Strategy and structure of diabetes health care in some European Socialist countries. Krall LP World Book of Diabetes in Practice. Vol. 3. Amsterdam, The Netherlands; Elsevier 1988: 375-376
    Google Scholar
  • 43 Shichiri M, Kishikawa H, Ohkubo Y, Wake N. Long-term results of the Kumamoto study on optimal diabetes control in type 2 diabetic patients.  Diab Care. 2000;  23 B21-B29
    PubMedGoogle Scholar
  • 44 St Vincent Group . Diabetes care and research in Europe.  Diabet Med. 1990;  7 360
    Google Scholar
  • 45 Starostina E G, Antsiferov M, Galstyan G R, Trautner Ch, Jörgens V, Bott U, Mühlhauser I, Berger M, Dedov I I. Effectiveness and cost-benefit analysis of intensive treatment and teaching programmes for type 1 (insulin-dependent) diabetes mellitus in Moscow - blood versus urine glucose self-monitoring.  Diabetologia. 1994;  37 170-176
    CrossrefPubMedGoogle Scholar
  • 46 The Diabetes Control and Complications Trial Research Group . The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.  N Engl J Med. 1993;  329 977-986
    Google Scholar
  • 47 UK Prospective Diabetes Study Group (UKPDS) . Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).  Lancet. 1998;  352 837-853
    CrossrefPubMedGoogle Scholar
  • 48 UK Prospective Diabetes Study Group (UKPDS) . Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes.  Br Med J. 1998;  317 703-713
    PubMedGoogle Scholar
  • 49 Vaccaro O, Imperatore G, Ferrara A, Polombino R, Riccardi G. Epidemiology of diabetes mellitus in Southern Italy: A case-finding method based on drug prescription.  J Clin Epidemiol. 1992;  45 835-839
    CrossrefPubMedGoogle Scholar
  • 50 Valle T, Koivisto V A, Reunanen A, Kangas T, Rissanen A. Glycemic control in patients with diabetes in Finland.  Diab Care. 1999;  22 575-579
    PubMedGoogle Scholar
  • 51 Winocour P H. Effective diabetes care: A need for realistic targets.  Br Med J. 2002;  324 1577-1580
    CrossrefPubMedGoogle Scholar
  • 52 World Health Organization .Diabetes mellitus. Technical Report Series 727. Geneva, Switzerland; WHO 1985
    Google Scholar
  • 53 Young M J, Boulton A JM, Macleod A F, Williams D RR, Sonksen P H. A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population.  Diabetologia. 1993;  36 150-154
    CrossrefPubMedGoogle Scholar

Priv.-Doz. Dr. med. Ralf Schiel (Medical Director and Head)

Department for Diabetes and Metabolic Diseases
Inselklinik Heringsdorf GmbH

Setheweg 11

17424 Seeheilbad Heringsdorf

Germany

Phone: + 4938378780500

Fax: + 49 383 78 78 04 44

Email: inselklinik.schiel@medigreif.de

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