The effectiveness of the Austrian disease management programme for type 2 diabetes: a cluster-randomised controlled trial

Abstract

BackgroundDisease management programmes (DMPs) are costly and impose additional work load on general practitioners (GPs). Data on their effectiveness are inconclusive. We therefore conducted a cluster-randomised controlled trial to evaluate the effectiveness of the Austrian DMP for diabetes mellitus type 2 on HbA1c and quality of care for adult patients in primary care.MethodsAll GPs of Salzburg-province were invited to participate. After cluster-randomisation by district, all patients with diabetes type 2 were recruited consecutively from 7-11/2007. The DMP, consisting mainly of physician and patient education, standardised documentation and agreement on therapeutic goals, was implemented in the intervention group while the control group received usual care. We aimed to show superiority of the intervention regarding metabolic control and process quality. The primary outcome measure was a change in HbA1c after one year. Secondary outcomes were days in the hospital, blood pressure, lipids, body mass index (BMI), enrolment in patient education and regular guideline-adherent examination. Blinding was not possible.Results92 physicians recruited 1489 patients (649 intervention, 840 control). After 401 ± 47 days, 590 intervention-patients and 754 controls had complete data. In the intention to treat analysis (ITT) of all 1489 patients, HbA1c decreased 0.41% in the intervention group and 0.28% in controls. The difference of -0.13% (95% CI -0.24; -0.02) was significant at p = 0.026. Significance was lost in mixed models adjusted for baseline value and cluster-effects (adjusted mean difference -0.03 (95% CI -0.15; 0.09, p = 0.607). Of the secondary outcome measures, BMI and cholesterol were significantly reduced in the intervention group compared to controls in ITT after adjustments (-0.53 kg/m²; 95% CI -1.03;-0.02; p = 0.014 and -0.10 mmol/l; 95% CI -0.21; -0.003; p = 0.043). Additionally, more patients received patient education (49.5% vs. 20.1%, p < 0.0001), eye- (71.0% vs. 51.2%, p < 0.0001), foot examinations (73.8% vs. 45.1%, p < 0.0001), and regular HbA1c checks (44.1% vs. 36.0%, p < 0.01) in the intervention group.ConclusionThe Austrian DMP implemented by statutory health insurance improves process quality and enhances weight reduction, but does not significantly improve metabolic control for patients with type 2 diabetes mellitus. Whether the small benefit seen in secondary outcome measures leads to better patient outcomes, remains unclear.Trial RegistrationCurrent Controlled trials Ltd., ISRCTN27414162.

Asociación del control glicémico con el apoyo familiar y el nivel de conocimientos en pacientes con diabetes tipo 2

“…Esto se ha demostrado cuando estrategias educativas a nivel individual o grupal evidencian un impacto positivo en el control de la enfermedad 11,32 . situación que no se observa al brindar atención médica sin incluir estrategias educativas 33,34 .…”

En forventet effekt

“…These findings underline the importance of having diabetes prevention and management programmes embedded in primary care settings. (Sönnichsen et al, 2010). The same research also noted that quality depends more on the care offered by a specific family physician than on the widespread implementation of a programme.…”

Diabetes Care Austria 2009: Register an allgemeinmedizinischen Ordinationen für PatientInnen mit Typ 2 Diabetes mellitus in Österreich

“…Knapp 81 % aller PatientInnen wurden mit (einem) antidiabetischen Medikamenten behandelt, wobei aber 5 % aller Typ 2 DiabetikerInnen mit einem HbA1c von größer 7,5 % gänzlich ohne antidiabetische Medikation war [30]. Von der gleichen Arbeitsgruppe wurden nun auch Resultate einer 1-jährigen Interventionsstudie bei diesen PatientInnen vorgelegt [31]. Die Intervention war die Teilnahme am DMP "Th erapie aktiv", das vor allem aus Schulungen für ÄrztInnen und PatientInnen sowie einer standardisierten Dokumentation als auch Übereinkunft bezüglich therapeutischer Ziele bestand.…”

“…Durch das DMP konnte zwar die Stoff wechselkontrolle nicht signifi kant verbessert werden, aber eine signifi kante Gewichts-sowie Cholesterinreduktion konnte in der Interventionsgruppe beobachtet werden. Ob diese Resultate eine bessere langfristige Prognose für die PatientInnen bedeutet, bleibt allerdings weiterhin unklar [31].…”