Position paper Diabetes care - Nivel



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 ( ).

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 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.

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 expenditure[i] .

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 amputation[ii]. Although the quality of diabetes care in many healthcare systems is gradually improving, this holds for a part of the patient population only[iii],[iv],[v],[vi]. Evidence suggests there is still a wide variation in quality of care, with rates of recommended care processes to be unacceptably low[vii],[viii],[ix].

3 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 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 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.

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 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. 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.

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 self-confidence and engagement among participating doctors and enhanced satisfaction of their patients.

Germany:

Since 2004 there are population wide disease management programs in Germany, Type-2-Diabetes 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 ().

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.

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.

4 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.

5 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.

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.

6 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 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

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[i] International Diabetes Federation. Diabetes Atlas. Brussels 2006. eatlas..

[ii] World Health Organisation. European Health Report 2002. WHO Regional Publications, European

Series, No. 97, Copenhagen.

[iii] 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.

[iv] Winocour PH. Effective diabetes care: A need for realistic targets. Br Med J 2002;324:1577-80.

[v] Hirsch IB. The burden of diabetes (care). Commentary. Diabetes Care 2003; 26:1613-4.

[vi] 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.

[vii] 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.

[viii] Jencks SF, Huff, ED, Cuerdon T. Change in the quality of care delivered to Medicare beneficiaries, 1998-

1999 to 2000-2001. JAMA. 2002; 289 (3): 305-312.

[ix] Saadine JB, Engelgau MM, Beckels GL, Gregg EW, Thompson TJ, Narayan KV. A diabetes report card

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