Diabetes in Europe, role and contribution of primary care –
Position paper draft 5, November 15th, 2007
The starting point
1. Content:
The Position Papers support practitioners, researchers and policymakers in Primary Care
by:
1. Clarifying concepts
2. Clarifying why this subject is a concern in/of Primary Care, and why it is (or should
be) a concern at international (EU) level.
3. Describing experiences and good practices; country or system characteristics that are
(un)favourable to these results.
4. Formulating lessons learned and the conditions under which good practices can
function.
5. Recommending policy measures on national and European level and identifying areas
for research.
2. Scope:
The papers deal with Primary Care in Europe, and therefore should be based and focus on
practice and policies in many countries or at least in a number of countries. Although
emphasis may be on EU countries, non-EU countries are included in the Forum and in its
activities. There is no objective to include information or evidence from all countries; it is
variation and diversity that counts. Highlights and issues count rather than completeness of
data: qualitative data above quantitative.
The paper has a maximum of 10 pages, excluding references and annexes.
3. The paper will be an extension of the position paper 2006 of the EFPC: The management
of chronic care conditions in Europe with special reference to diabetes: the pivotal role of
Primary Care edited by Luk Van Eygen, Patricia Sunaert, Liesbeth Borgermans, Luc Feyen,
Jan De Maeseneer (http://www.euprimarycare.org/smartsite.dws?ch=DEF&id=1169 ).
Introduction
Diabetes is a chronic condition associated with multiple late complications, reduced life
expectancy and a marked limitation in quality of life. Among diabetic patients mortality per
year is about twice as that in the normal population and life expectancy is about five to ten
years shorter. The disease, its complications and late onset consequences cause a dramatic
burden for health systems (Ref).
This position paper focuses on the pivotal role of primary care in diabetes mellitus and
targets policymakers in the EU and its member states. We argue the need for a concerted
approach to define how programs to manage diabetes mellitus should be designed,
implemented and evaluated to ensure the highest level of quality care delivery across the
different European healthcare systems.
1
1
Definition and classification :
Diabetes mellitus is a group of endocrine disorders characterised by hyperglycaemia as a
consequence of disturbed secretion or function of insulin. Severe hyperglycaemia leads to the
classical symptoms of diabetes such as polyuria, polidypsia and weight-loss. Acute
complications of severe hyperglycaemia include ketoacidosis and non ketoacidotic
hyperosmolar syndrome with the potential for the dangerous condition of coma. Chronic
hyperglycaemia in diabetic subjects is associated with long term complications and decreased
functioning of several organs and tissues, especially the eyes, kidneys, the nervous systems,
the heart and blood vessels.
The following four types of diabetes can be classified (reference):
1. Type I diabetes: disordered insulin secretion due to destruction of the beta-cells in the
pancreas with mostly absolute deficiency of insulin. A special form with slowly
developing deficiency of insulin secretion is known as latent autoimmune diabetes of
adults (LADA).
2. Type II diabetes: disorder of insulin effects (insulin resistance) with relative deficiency
of insulin (typically a disorder of glucose dependent insulin secretion).
3. Other specific types of diabetes: these are caused by diseases of the exocrine pancreas
or other endocrine organs or might develop due to pharmacological causes, genetic
defects or syndromes or infections.
4. Gestational diabetes: this type develops for the first time during pregnancy as a
disorder of glucose tolerance.
Diabetes mellitus is diagnosed primarily by multiple measurements of elevated fasting
glucose values on at least two different days in plasma or full blood. Quality assurance of
tests is an absolute requirement. Devices designed for self measurements by patients are
not accepted to establish the diagnosis. In suspected clinical situations and in case of
contradictionary results, the diagnosis is based on the oral glucose tolerance tests. An
impaired fasting glucose and an impaired glucose tolerance have been defined with their
specific lower and upper limits and are considered the early forms in the development of
diabetes (prediabetes, see table 1). The results of measurements can be twingled by
dehydration, infections or certain drugs (e.g. glucocorticoids). The determination of
glycosylated haemoglobin (HBA 1c) alone is currently not suited for making the diagnosis
and is used exclusively as follow up parameter in long term care and for the control of
setting the glucose level.
While type I diabetes with its typical symptoms and acute onset is usually diagnosed quite
early, the diagnosis of type II diabetes usually is preceded by a longer symptom free
interval. However, insulin resistance and a disorder of insulin secretion does exist in these
patients long before the disease becomes manifest; the existing hyperglycemias very often
already at this time leads to an increased risk of stroke, myocardial infarction and
peripheral arterial obstructive disease. Measures for prevention and early recognition of
type II diabetes are therefore of prime importance. In the office of the family physician
and based on the long term relationship between a patient and his/her family physician,
multiple consultations and health checks offer a very good opportunity to assess risk
factors or early suspicious symptoms and to identify patients with increased risk for
developing diabetes.
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2
Epidemiology
Type II diabetes is the most common form of the disease and is usually diagnosed past the
35th year of life. Five to 15 percent of all diabetic patients suffer from diabetes type I (juvenile
diabetes). In the last couple of years, an increased prevalence of type II diabetes among
adolescents has been observed. Type II diabetes, therefore, develops away from a disease of
elderly people and becomes more and more a problem for people in their first half of life.
The impact of diabetes on health in Europe can hardly be underestimated. In 2003 the
International Diabetes Federation estimated that about 48 million people in Europe suffer
from diabetes. This corresponds to a prevalence of 7.8%, which is expected to rise to 9.1%
by 2025. By 2025 the direct cost of diabetes is expected to represent between 7% and 13%
of the total health expenditure1 .
Diabetes has a dramatic impact on mortality, morbidity and quality of life. Diabetes patients
have 3- 4 times as much risk to die from cardiovascular diseases. Diabetes is still the most
common cause of blindness at working age, one of the most common causes of kidney
failure and the most common cause of leg amputation2. Although the quality of diabetes care
in many healthcare systems is gradually improving, this holds for a part of the patient
population only3,4,5,6. Evidence suggests there is still a wide variation in quality of care, with
rates of recommended care processes to be unacceptably low7,8,9.
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Experiences and practices
Austria:
The starting point for a new area in the care for patients with diabetes is rooted in a landmark
publication, the Austrian Diabetes Report (Ref.). This survey aimed to assess the trends for
Austria and to estimate the extend of the diabetes epidemic. The study showed huge deficits
in care documentation, prevention and research on diabetes. As a consequence, a group of
experts was formed to work out a strategy to improve the deficits and the care situation in
Austria. This interdisciplinary group included specialists, general practitioners, social workers
and representatives of self help groups. Because of a lack of information regarding the
frequency of diabetes at the population level it was recommended to develop a standardized
diabetes register. Further, the need for an appropriate infrastructure was put forward in order
to provide sufficient lifestyle and treatment measures for those affected. Clear target groups
were identified, which reflect the results of most international studies: Socially weaker
populations of both sexes and city dwellers. It was recommended to develop programs which
in particular address and involve these target groups. Strengthening health promotion
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measures and their application and building networks in health promotion were considered
important leading strategic aims for diabetes prevention(ref).
In addition, a research project was conducted in one of the counties of Austria (ref). The
results underlined the efficiency of a structured care model based in primary care, which was
characterized by high acceptance, improvement in the quality of processes, clinical
parameters and costs.
Together, this study and the strategy developed formed the basis of a national consensus on
the prevention and management of Diabetes mellitus type II at the population level. This
consensus/guideline was developed by the “Austrian Diabetes Association” and the Austrian
Diabetics Association together with the Austrian Society of General Practice and Family
Medicine. In cooperation and with the support of the Health Insurance Company this
guideline later on evolved into a Disease Management Program for Diabetes which was
implemented in parts of Austria in 2007, is concomitantly evaluated and will be extended to
all of Austria within the next year.
In conclusion, the national survey described above formed the basis of a national strategy,
which was translated into a guideline and a DMP ready for implementation at the primary
care level. The fact, that all these steps have been carried out by an interdisciplinary team
involving all health care professionals, patients representatives, social workers and
representatives of payers proved to be crucial for the acceptance of the concepts developed as
well as for the implementation of the guideline.
Switzerland:
No specific concept for managing patients with diabetes is in use, maybe because Swiss
doctors (and politicians) are too sensitive to regional (cultural) differences. Quality of medical
practice is assumed to be at an acceptable level through (qualified) continuous medical
education, i.e. by self-responsibility of the doctor; further, it is expected that he/she has a
network of diabetes nurses, health consultants, dieticians, podotherapists and medical experts
(endocrinologists, ophthalmologists) at his/her disposal. A few efforts are aiming to enable
doctors to manage an interdisciplinary setting, e.g. by the Division of Therapeutic Education
for Chronic Diseases at the University Hospital of Geneva or the Swiss Diabetes Study
Group, both institutions primarily pursuing the education of the patients. Currently the first
Departments for General Practice are about to be established and it seems clear that
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standardized management of patients with diabetes will be one of the important topics to be
addressed.
Rumania:
The official data for prevalence of Diabetes Mellitus is 1,8 % in Rumania; however, this data
don’t reflect the real prevalence because there are no national epidemiological studies or a
national screening program. The costs for diabetes (still high) rises approximately 3-5 times
that of the CODE -2. From 1990-2006 all patients with diabetes type 1 and 2 were cared for
and monitored only by diabetes specialists. Treatment with insulin and oral antidiabetics
(ADO) was covered by the Health Ministry and provided at the hospital’s pharmacies with
closed turnover but this agglomeration and the lack of medicines was criticized in mass
media. In 2007 the Ministry of Health decided to involve family doctors also in the
distributions of oral medication (refill prescription) and a CME national program for all
family doctors was developed. Now trained family doctors have the permission to prescribe
ADO after the specialist has seen the patient.
In 2005 the National Center for Studies in family Medicine developed the first guideline
“Diabetes Mellitus 2 nd type, Guideline for practice of Family Doctors” with MATRA
assistance (Netherlands program). The institution presents and implements this guideline
through a number of regional workshops.
In the past, for a new patient with Diabetes Mellitus only the Diabetes specialist could
confirm the diagnosis. However, in 2007 the Health Ministry Diabetes Commission offered to
Romanian family doctors a new protocol for detection and documentation, screening,
evaluation, treatment and follow up, monitoring the patients with DM tip 1 or 2 including
comorbidities. Since August 2007 all Romanian citizens received a special invitational letter
by the Health Ministry offering a clinical examination and a prophylactic laboratory test and
an evaluation of people over 45 or those with risk factors is recommended. This program
really improved the detection of new cases. Among the problems are the facts that only 10 15 % of patients have an opportunity for self measuring glucose levels and some specialists
refuse to communicate.
In the near future, the National Society for Family Doctors will propose to our Health
Ministry a new system to monitor patients with DM type 2, to allow family doctors to send
patients to measurement of HbA1c, to improve the communication in the care team, to build
a national electronic register for the disease and to improve our medical software programs
for prophylactic surveys.
France:
All patients with Diabetes Mellitus type 2 (DM2) should be registered with the French
national health insurance system and, therefore, have 100% coverage by the public health
system. But since the registration is based upon a voluntary decision negotiated by the GP and
the respective patient, DM2 prevalence of the disease in France is underestimated. The
number of patients on this national register is 1 300 000 , far away from the over 2 500 000
estimated by different diabetes specialists groups.
5
National guidelines cover recommendations for early recognition, screening, structured long
term care, special problems such as comorbidities, prevention and therapy. While these
guidelines have been implemented, their efficiency hasn’t been evaluated yet. Very little
attention was paid to the arguments of primary care experts participating in their
development, which leads to a situation of low compliance among some GPs.
France has yet to set public health targets, define the needs for research, and clarify the
respective roles of the various health practitioners. While the development of a structured
network dedicated to the management of patients with DM2 is strongly encouraged and
financed, the programs developed so far do not aim at patients needs and have no agreed
goals.
Finland:
As in many other industrialized countries the prevalence of type 2 diabetes (DM2) is rapidly
increasing in Finland and estimated to rise 70% from the year 2003 by 2010. At least half of
the DM2 patients are suspected to be undiagnosed; even a larger proportion suffers from
impaired glucose tolerance. Additionally, Finland has the world’s highest and growing
incidence of type 1 diabetes (DM1), which consists 10-15 % of all diabetes cases. According
to some previous reports (Valle et al) the glucose level of DM2 patients had improved from
the early1990’s to the beginning of this century, while no improvement had occurred in the
DM1 patients’ HBA1c levels despite the introduction of new insulin analogues.
To improve the care and management of some major chronic diseases in primary health care a
quality network of health centres was started in 1997. Among others, improvement in the
quality of care of DM2 is one of its aims. The network has grown to cover one third of our
country.
Knowing the unsatisfactory situation in the care and treatment targets of diabetic patients, the
Finnish Diabetes Association (FDA) started a national action plan, the Development
Programme of Diabetes Prevention and Care (DEHKO) at the beginning of this century. It
aims both at earlier and better diagnosis, treatment and management of DM2 patients and
also at prevention. Primary health care professionals and occupational health care
professionals are mainly responsible for the diagnosis, health care and treatment of DM2
patients, while that of adult DM1 patients’ are either in the responsibility of skilled primary
health care units or in hospital clinics depending upon local practices.
The FDA has published several guidelines on the treatment of type 1 diabetes, but not for
DM2. Also, the Finnish Medical Association Duodecim has so far published Current Care
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Guidelines on appr. 70 major public health or other important medical issues since 1997, but
it was only in 2007 when Current Care Guidelines on diabetes, mainly in accordance with the
guidelines of the International Diabetes Federation for both DM2 and DM1 were
introduced ( ).
Encouraged by the Finnish Diabetes Prevention Study the FDA planned and started in
cooperation of other actors the implementation of the type 2 diabetes prevention program
aiming at prevention of DM2. The strategy of early diagnosis and management aims at a
diagnosis before macrovascular complications have developed and bringing the patients into
the sphere of treatment and management as early as possible to prevent complications. The
building of a national diabetes register would enhance both the planning and the management
of diabetes care.
Spain:
The health care system in Spain is primary care based; every family physician (FP) has a list
of about 1800 people (among them approx.100-200 diabetic patients) and acts as a gate
keeper. DM1 is generally attended by paediatricians in primary care and/or by
endocrinologists in the Hospital. DM2 is usually diagnosed and treated by FP´s and patients
are mainly referred to endocrinologists for diagnosing or treating complications or for the
beginning of insulin treatment.
In the 80`s the prevalence of DM2 was 6% and in the 90`s and in 2000 the prevalence is 10%
( ) with even higher values in some regions (Catalonia, Canary Islands, Asturias). Incidence of
DM2 is 8/1000 population/year in people over 30 years of age ( ). Another important question
is the relationship between known and unknown diabetes that is 1:1 in some studies and 2:1 in
others. Prevalence of DM1 has been estimated to be 0.2% to 0.3% and the incidence is
11/100000 population/year in people under 14 years of age ( ). The burden of diabetic
complications follows the European trend; diabetes mellitus is the third leading cause of
mortality in women and the seventh in men.
According to the Saint Vincent Declaration of 1989, several Diabetes Advisory Boards
(DAB) were created in each of the 17 regions in Spain, with the participation of FP´s,
endocrinologits, pediatricians, nurses, health authorities, etc. These DABs developed
guidelines for early recognition, screening, diagnosis, treatment and management of the
disease. The first structured long term care programme was presented and implemented in
Valencia in 1999, other regions followed. There are guidelines from the Spanish Society of
Diabetes, the Spanish Society of Family Medicine and Spanish Society of Nephrologists.
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While guidelines from international societies such as EASD, IDF and ADA are also used they
haven’t been evaluated yet. The GEDAPS guideline prepared by FP is updated every year.
However, studies about quality of care document low adherence to guidelines
recommendations ( ).
As recent as in 2006 a National Strategy for Prevention, Diagnosis and Treatment of Diabetes
has been initiated, in which all professionals involved in the care of diabetic patients in Spain
participate. This Strategy includes intervention programmes and an obligatory evaluation.
Slovenia:
The health care system in Slovenia is primary care based; every family physician (FP) has an
average list of 1700 patients and acts as a gate keeper. Due to the high mortality rate on
cardiovascular diseases there is a nationwide program on prevention of CVD in place. Blood
sugar levels are thus checked once in five years in all men after 35 years and in all women
after 45 years by the FPs with whom patients are registered. Each pregnant woman has a
blood sugar profile done during prenatal clinics. As a part of CVD prevention and health
promotion programme promotional activities take place, i.e. individual and group counselling
regarding healthy diet and physical activities.
In the 90`s the prevalence of DM2 according to national register was 3%, but estimated to be
4% or even higher. Newly detected patients are diagnosed according to guidelines and are
treated partly in FP, partly still in diabetic hospital outpatient clinics, because there is not any
financial incentive to care for diabetic patients in primary care. DM1 patients are generally
registered with diabetologists in the hospital outpatient clinics. DM2 is usually diagnosed by
FP´s; traditionally, however, the majority of patients in urban and suburban areas were
referred to the diabetic hospital outpatient clinics and only recently diabetologists do not urge
patients to visit these clinics for their regular treatment. The clinics were established in the
early sixties, with the main aim to provide quality care. They kept national register of diabetic
patients visiting. Dieticians, educationalists and sub specialized services were attached to the
clinics in order to provide multidisciplinary care. Only recently, more patients are managed by
their FP’s. A big national diabetes patients association has an important impact on public
health policy regarding diabetes care. International guidelines on diabetes care are approved
by national societies and criteria for diagnosis and treatment targets are incorporated in daily
practice. Besides metabolic control diabetic retinopathy clinics and foot care clinics are in
place to deal with those complications. Insulin treatment in DM2 is initiated and managed by
diabetologists in diabetic hospital outpatient clinics.
8
The organisation and health policy regarding diabetes control in Slovenia is mainly money
driven, which means, that the diabetologists have less interest now in taking care for diabetic
patients as in the past, but FPs are not inclined in taking over the burden of a large number of
chronic patients without any financial incentive.
Turkey:
The prevalance of diabetes in the Turkish population (68 million) has been reported
as 3.4 – 7.2 % (2-4). The prevalence has been rising at an unprecedented rate,
along with the obesity “epidemic”, according to data provided by both TURDEP (4)
and the Turkish Adult Risk Factor Study (5). Co-morbidity is a major problem; silent
ischemia has been shown in 12.4% of patients with diabetes (6). The prevalence of
type 2 DM has been found to be 17.9% among hypertensive patients and was even
higher in smokers (7).
Enhanced effectiveness of oral therapy after an 8-week educational intervention
program has been shown (8). A cluster RCT study ongoing in Antalya shows also
promising preliminary results concerning quality of life and metabolic control after a
short educational intervention by primary care doctors, using the 5-minute survival kit
of Diabetes Education Stuyd Group (DESG). These findings have been supported by
a study, which showed a two-fold higher sense of well-being in patients attending a
diabetes education program (9).
Despite efforts to deliver high quality diabetes care, a countrywide survey in 11 cities
and with 305 doctors showed a predominance in oral therapy with a single drug, a
suboptimal treatment (10). This was also shown in a study performed in western
Turkey (11): Oral therapy predominated, the median blood glucose level was 169
mg/dl and preventive services were lacking.
Even if specialists might provide the better quality care in the hospitals, the high
prevalence of diabetes calls for the contribution of primary care at the community
level. There, in a setting with lack of resources a 5-minute survival kit might also help
to empower patients for better self-care. A collaborative initiative aimed at medical
practitioners to attend a training course at the University shows an increase in selfconfidence and engagement among participating doctors and enhanced satisfaction
of their patients.
Germany:
Since 2004 there are population wide disease management programs in Germany, Type-2Diabetes was the first one. General treatment goals have been defined (), among them: Few
hypoglycemic episodes, increasing the percentage of patients with normotonic blood pressure
from 10 to 20%, more patients without diabetes-related symptoms, fewer patients with newly
diagnosed diabetes-related diseases such as nephropathy, neuropathy, etc.
Participation in the program is supported by financial benefits. Doctors receive for every
quarterly or biannual DMP examination on average 20 € and most patients are reimbursed for
the 10 € personal contribution they have to pay at the GP´s office.The disease management
program includes a set of examinations, an educational program and structured feedback ().
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The DMP was heavily discussed in Germany. Most doctors feel to be controlled and teased by
bureaucracy. The main scientific critic is that this gigantic program was implemented without
concomitant evaluation or a control group of patients for comparison. The amount spent for
this program are not justified by scientific evidence.
On the other hand that treatment goals have to be discussed and decided between doctor and
patient in mutual respect is considered a great advantage of the program.
Lithuania:
The morbidity of DM type is estimated between 2 - 4.2 % of population. Since 1997 there is a
register of DM patients; approx. 2% of the population are registered. Less than 35 % of DM
patients have sufficiently controlled glycaemia and the delay in initiating appropriate
treatment is approx. 6-8 months.
Family physicians are responsible for diagnosis and treatment of DM type 2; they are not very
experienced and confident with insulin therapy; further, the attitude of the population is rather
against the use of insulin. Non medical treatment or measures for prevention such as
modification of life style is not structured and unavailable.
In 2006 a strategy for DM control was approved, which includes early assessment of risk
factors and early diagnosis of DM, control of DM glycaemia, education of family doctors and
education of the population. For implementation of this program, the responsibility and main
resources have been allocated to endocrinologists and scientists. The outcome is not known
yet.
Denmark:
More than 90 % of all Type 2 Patients in Denmark are cared for by general practitioners.
Most Type 1 patients are taken care of by hospital outpatient clinics.
The Danish College of General Practitioners has - since 1991 - produced guidelines for Type
2 Diabetes. The guidelines are continuously being updated. The latest version number 6 is
evidence based and printed in 2004. The Diabetes Group under the The Danish College of
General Practice is working with quality improvement and implementation of the guidelines.
In the latest contract between general practitioners and The Public Health Service there has
been a special focus on treating patients with Type 2 Diabetes. General practitioners are
offered a special fee in order to develop and insure the quality of treatment for people with
Type 2 diabetes, and are given an electronic instrument to add to their electronic patient
records in order to plan and quality assure the care for people with Type 2 Diabetes. More
than 90% of Danish GPs have electronic patient records. General practitioners are free to join
this concept, but joining means that the general practitioners have to register key quality
measures to a national database for all the Type 2 Diabetic patients. This new concept will be
evaluated in 2008.
Since 1997 it has been possible through reliable registers to follow the prevalence and quality
of care in one county in Denmark and since year 2002 in two counties. Initially the quality of
care was not optimal leaving 27 % without a HbA1c measurement within the last year and
almost 60 % without an eye-examination within the last year. New data show that up until
2004 there have been an increasing prevalence of Type 2 Diabetics, an increasing number of
patients have HbA1c measurement and an eye-examination within a year, and an increasing
number have HbA1c levels within good to moderate control.
10
Research within Type 2 Diabetes in general practice is mainly carried out at The Research
Unit for General Practice in Copenhagen and The Department of General Practice, Institute of
Public Health, University of Aarhus. Both institutions are working with quality assurance,
quality improvement and randomised controlled trials in order to evaluate and improve
diabetes care.
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lessons learned
From the country reports provided above we can summarize as follows:
1. Care of diabetic patients is differently organized across Europe. The level or degree of
organisation varies widely and apparently depends on both the status of the health care
system and the level of professional involvement.
2. Based on available data the prevalence of diabetes mellitus type II is believed to be
underestimated.
3. The situation of the quality of care of diabetic patients is unsatisfactory.
4. Countries which have a monitoring system and are registering patients with diabetes
mellitus have a better picture than countries without such a register.
5. The development of guidelines alone or their availability alone does not significantly
improve quality of care for patients with diabetes. Acceptance of and adherence to
guidelines or their recommendations is low and unsatisfactory.
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recommendations
To improve the quality of care for patients with diabetes the position paper 2006 (reference)
put forward arguments for the chronic care model as a basis and its foundation routed in
primary care has been underlined. These general principles have been summarized as
follows:
 Patients should be active and empowered partners in diabetes care
 Diabetes care should be provided by an interdisciplinary team
 Quality monitoring is a prerequisite for efficient diabetes management
 Information and communication technology are crucial to facilitate integrated
diabetes care
 Prevention and early detection of diabetes require more attention
Based on the information and data collected or available, this paper would like to provide
further recommendations to improve the quality of care for diabetic patients:
1. National registers for patients with diabetes should be established and maintained to
have up to date information available for calculation of prevalence and incidence.
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2. An interdisciplinary team of professionals together with all other players or payers
involved should agree on common goals at the national level and should develop
harmonized, standardized recommendations based on scientific evidence for the care
of patients with diabetes. This would help to improve acceptance of such
recommendations.
3. To improve adherence among professionals and patients to the recommendations
developed a system of incentives for providers and consumers should be developed
and included as an integral part when implementing national programs or
recommendations.
4. Providers and patients should be well informed about such programmes by appropriate
means and should be systematically and obligatory educated or trained.
5. Effects and efficiency of programmes implemented should be systematically
documented and concomitantly evaluated.
6. Screening of high risk patients for impaired glucose tolerance should be considered.
7. Programs should be implemented and conducted at the community level by trained
primary care physicians.
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Conclusions
The different stages of developments in the organisation of diabetes care in Europe illustrate
the transition process European health systems are going through. They were designed in
the middle of the 20th century to deal mainly with acute diseases, but due to the progress of
medicine and the ageing of the European population, the focus has shifted towards chronic
disease management. Diabetes care is one of the fields where the implementation of these
changes has reached the furthest so far. Important choices have to be made, which don’t
affect diabetes care only, but also the overall health care organisation. In 2006 we strongly
plead for a diabetes care model rooted in primary care. Primary care offers holistic,
comprehensive and continuing care to the diabetes patient. Evidence has clearly shown that
well structured primary care can provide high quality diabetes care.
It is clear that at present many health care and primary care systems in Europe aren’t
prepared to take up this task. In addition to global payment systems, patients’ listing and a
gatekeeper role for the general practitioner ( ) we strongly recommend obligatory registration
of patients, development of national guidelines by all players involved, provision of incentives
to improve adherence to such guidelines in primary care, education of patients and training
of professionals and regular evaluation of such programmes through health services
research projects. Finally, screening for impaired glucose tolerance among high risk
individuals should be considered and be a focus for research.
These reforms will not only have their impact on diabetes care, but will strengthen the
position of primary care within each health care system and make the future implementation
of other chronic disease management programmes in primary care easier. Therefore, the
debate on the diabetes care organisation, its consensual development and harmonization, its
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efficient implementation and systematic evaluation at the national level reflects the
fundamental choices the European health care system, professionals and consumers have
to make at the beginning of the 21st century.
References
1
International Diabetes Federation. Diabetes Atlas. Brussels 2006. www.eatlas.idf.org.
2
World Health Organisation. European Health Report 2002. WHO Regional Publications, European
Series, No. 97, Copenhagen.
3
Shaughnessy AF, Slawson DC. Blowing the whistle on review articles-What should we know about the
treatment of type 2 diabetes? Editorial. Br Med J 2004; 328:280-2.
4
Winocour PH. Effective diabetes care: A need for realistic targets. Br Med J 2002;324:1577-80.
5
Hirsch IB. The burden of diabetes (care). Commentary. Diabetes Care 2003; 26:1613-4.
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Goyder EC, McNally PG, Drucquer M. et al. Shifting care for diabetes from secondary to primary care,
1990-5.: review of general practices. BMJ 1998; 316:1505-6.
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McBean AM, Jung K, Virnig BA. Improved care and outcomes among elderly Medicare managed care
beneficiaries with diabetes. Ma J Manag Care 2005; 11: 213-222.
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Jencks SF, Huff, ED, Cuerdon T. Change in the quality of care delivered to Medicare beneficiaries, 19981999 to 2000-2001. JAMA. 2002; 289 (3): 305-312.
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Saadine JB, Engelgau MM, Beckels GL, Gregg EW, Thompson TJ, Narayan KV. A diabetes report card
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