Diabetes mellitus affects about 7% of the populations of Canada and the United States -some 23 million people -and accounts for direct annual health care costs of about $105 billion.1,2 At least 90% of people with diabetes have type 2 diabetes. In addition to being a major risk factor for cardiovascular disease (whereby the risks of myocardial infarction and stroke are 2-4 times those in the nondiabetic population), diabetes is the primary cause of renal failure, blindness and nontraumatic limb amputation.1,2 International guidelines recommend interventions to prevent these complications, mainly on the basis of evidence from large randomized clinical trials.3-7 These interventions include control of glucose, blood pressure and lipids; vascular protection with acetylsalicylic acid; diet; exercise; renal protection; smoking cessation for smokers; prevention and treatment of retinopathy; and education about foot surveillance. In a recent study, intensive intervention to address multiple risk factors was associated with lower rates of mortality (by 56%), cardiovascular events (by 59%), nephropathy (by 56%) and retinopathy (by 55%) over 13 years relative to conventional therapy. 8 These major changes in the frequency of events occurred despite the small differences (0.3% for glycated hemoglobin, 6 mm Hg for systolic blood pressure and 0.2 mmol/L for low-density lipoprotein [LDL] cholesterol) between groups by the end of the open follow-up period. However, optimal care of patients with diabetes in the community has been difficult to achieve, because it can be difficult to sustain regular monitoring and attention to many risk factors over many years, especially for patients with multiple health care providers. 9,10 Most diabetes care takes place in the community, largely managed in the primary care setting. In this environment, short visits, competing visit objectives, lack of proactive systems for disease surveillance and alerting support, difficulties staying up to date on ever-shifting targets, challenges associated with managing multiple medications and inertia related to chronic disease (on the part of both patient and physician)

Almost half of MMIT interventions improved the process of care, but few studies measured clinical outcomes. This large body of literature, although instructive, is not uniformly distributed across settings, people, medication phases, or outcomes.

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The web-based prototype decision support system slightly improved short-term risk factors. The model predicted moderate improvements in long-term health outcomes. This disease management program will need to develop considerable efficiencies in terms of costs and processes or improved effectiveness to be considered a cost-effective intervention for treating patients with type 2 diabetes.