Abstract

Objective: The aim was to evaluate the Saxon Diabetes Management Program (SDMP) which is based on integrated practice guidelines, shared care and integrated quality management. The SDMP was implemented into diabetes contracts between health insurances, GPs and diabetes specialised practitioners (DSPs) unified in the Saxon association of Statutory Health Insurance Physicians.

Research Design And Methods: The evaluation of the SDMP in Germany represents a real world study by using clinical data collected from participating physicians. Between 2000 and 2002 all DSPs and about 75% of the GPs in Saxony participated. Finally 291,771 patients were included in the SDMP. Cross-sectional data were evaluated at the beginning of 2000 (group A1) and at the end of 2002 (group A2). A subcohort of 105,204 patients was followed up over a period of three years (group B).

Results: The state-wide implementation of the SDMP resulted in a change of therapeutic practice and in better cooperation. The median HbA1c at the time of referral to DSPs decreased from 8.5% to 7.5% and so the overall mean did. At the end, 78% and 61% of group B achieved the targets for HbA1c and BP, respectively recommended by the guidelines compared to 69% and 50% at baseline. Poorly controlled patients benefited the most. Pre-existing regional differences were aligned.

Conclusions: An integrated care disease management with practicable integrated quality management including collaboration between GPs and specialist services is a significant innovation of chronic care management and an efficient way to improve diabetes care continuously.