Evaluation of a Teaching and Treatment Program in Over 4,000 Type 2 Diabetic Patients After Introduction of Reimbursement Policy for Physicians

The Styrian Diabetes Type 2 Education Project is a combined intervention consisting of a structured DTTP and a special training for the educating staff. The DTTP is a 16-h course, conducted at the primary health care level. It is well evaluated and transferable (6–10). The program covers nine education areas: basic diabetes information, self-monitoring, medication and hypoglycemia, diet, foot care, physical activity, sick day rules, and late complications. Training of the educators (physicians and diabetes educators) focuses on the discussion of evidence-based therapy and therapy goals. Role-playing techniques are used to improve patient education skills. One year after the initial teaching program, a 2-h refresher course including a follow-up assessment is held. The remuneration for one training course (6–12 participants) is $870 and $183 for the follow-up.

The project is supported by a quality management concept using a documentation form that includes most of the data proposed by the European Diabetes Indicator Project (EUDIP) (11). This form must be completed for each patient at baseline and at follow-up. Every 3 months, a benchmarking report is compiled and sent to each participating physician. An annual report analyzes the effects of the program that suggests adaptations to the steering committee, which reviews current data biannually. A postgraduate meeting is offered twice a year.

During 4 project years, 120 physicians and 52 diabetes educators taught the DTTP course to 4,396 patients with type 2 diabetes (55% female, aged 63.8 ± 10.7 years, diabetes duration 5.0 ± 6.2 years, BMI 29.7 ± 5.1 kg/m², baseline A1C 7.6 ± 1.6%; all mean ± SD). A total of 2,122 (48%) individuals attended the follow-up assessment. All target parameters significantly (P < 0.001) improved after 1 year (A1C −0.4 ± 1.3%, BMI −0.4 ± 2.4 kg/m², body weight −1.1 ± 6.2 kg, systolic blood pressure −1.8 ± 19.3 mmHg, diastolic blood pressure −1.1 ± 10.8 mmHg, cholesterol −0.1 ± 1.1 mmol/l, LDL cholesterol −0.2 ± 0.9 mmol/l, and triglycerides −0.1 ± 1.8 mmol/l). Changes in glucose-lowering treatments are illustrated in Fig. 1. Although insulin therapy was not an inclusion criterion, 1.1% of the patients were already on insulin at baseline and 6% at follow-up. Sixty-six percent of the patients had eye examinations within 1 year before the course and 69% (P = 0.04.) at follow-up. The rate of foot examinations did not change significantly (86–85% at follow-up, P = 0.28).

More information on the project, the documentation form, statistical analysis, baseline characteristics, change in A1C, and treatment for arterial hypertension and blood lipids are available in an online-only appendix (available at http://dx.doi.org/10.2337/dc06-2095).

Our evaluation demonstrates that a teaching and treatment program for patients with type 2 diabetes can successfully be implemented throughout the area at the primary health care level. Our large-scale cohort showed an improvement of all target parameters with an A1C reduction comparable to previous randomized studies (12,13). The relative increase of patients treated with biguanides at follow-up may account partly for the decrease of A1C and for the observed weight reduction. Apart from the effects of the training program, including improved drug intake compliance, increase of physical activity patterns, and changes in nutritional habits (9,10), the metabolic improvement could be further explained either by an increase in medication dosage or by initiation of insulin therapy.

The low follow-up rate is a limitation of the project. Randomized controlled trials on similar topics obtain follow-up rates of at least ∼80% (2), while in interrupted time series and before-and-after studies, which are more comparable to our study, these rates are seldom achieved. However, sustained implementation of education programs within the health system has rarely been subject to evaluation in the literature. Through a standardized questionnaire sent to participating physicians, reasons for the low follow-up rate were determined. The most common response was that operating expenses for documentation are too high and that remuneration for the follow-up examination is not attractive. Otherwise, based on physicians' opinions, patients do not show up at follow-up because of loss of motivation, a guilty conscience because they did not modify their behavior after the training course, or they do not see the sense of a follow-up, having already heard everything in the initial course. It is possible that the patients lost to follow-up were less successful in reaching their treatment targets than the others. One can speculate whether a personal reminder for patients, as installed for physicians, would have further increased the follow-up rate.

The introduction of a structured documentation led to a more accurate and comprehensive monitoring of the patient. Eye examination rate (69%) was clearly higher compared with a survey (57.6%) by Saaddine et al. (14). The early educational intervention and intensified screening and treatment for secondary complications in our program will likely postpone the outbreak of diabetes-related comorbidity as previously shown in disease management programs (15,16).

In conclusion, our investigation demonstrates, by means of improved intermediate outcome parameters, that a teaching and treatment program for patients with type 2 diabetes who are not using insulin for glycemic control was successfully implemented province wide at the primary health care level.

The authors thank all members of Forum for Quality Systems in Diabetes Care, the Styrian Medical Association, the regional health insurance fund (Gebietskrankenkasse), the Styrian government, and all participating physicians and diabetes educators.