Problems of realising secondary prevention in diabetes care

Several researchers point to the need to intensify therapy and secondary prevention concerning the management of coexisting risk factors in patients with type 2 diabetes [1, 2, 3].

Besides the challenge of financing, the critical question of today is less ‘if’ but much more ‘how’ appropriate management should be realised. There is a common sense insight that efficient interventions, which avoid typical after effects or at least delay the individual aetiopathology, are sensible from the medical and the economic point of view. But, which are efficient measures and which are not? When and for which patient groups are these measures effective? Several questions arise which can only be answered on the basis of epidemiological research.

Intervention measures are able to affect management and secondary prevention on three levels, health care system (population) level, provider level and patient level.

Fig. 1: Interventions on population (DMP) level

The computer-assisted approach discussed here aims to improve diabetes management opportunities on population, provider and patient level. At provider level difficulties invdiabetes care usually arise from a lack of evidence based information [4] in combination with a lack of time spent per patient [5]. Especially, stratification and assessment of individual risks seems to be a task general practitioners have difficulties to cope with [6]. Furthermore, physician’s time to search for individual patient related information and time for risk communication is limited [7].

The German health system in particular suffers from weaknesses in the secondary prevention of cardiovascular risk factors. Often the focus of diabetes therapy is only on blood glucose levels. In view of this problem, several researchers recommend a reconsideration of general treatment conditions in medical practices [8]. There is the need to focus on individualised evidence based care. In recent years, the evidence basis could have been improved through the implementation of care guidelines. Nevertheless, the lack of individualisation in diabetes care still persists. Despite those challenges there are also more practical difficulties in realising secondary preventive measures on provider level. On the one hand interventions have to be implemented in effective work routine in daily practice. On the other hand the medical benefit has to be in due proportion to costs.

Fig. 2: Interventions on case management level

On patient level the challenge comprises in handling other obstacles. One lasting problem in the life of diabetes patients as well as for people with other chronic diseases is the issue of very high non-compliance rates [9, 10]. The subjective feeling of well-being during the treatment can easily lead to reduced health awareness by patients and subsequently to non-compliant behaviour [11]. On a continuous basis, this increases complications in the long-term. Thus, the question of how compliance can be obtained and sustained also becomes a medical problem. Experiences show that patient education alone is not enough to ensure compliance. The doctor-patient-relationship plus an adequate case management of the disease play an important role [12, 13].

Patient empowerment together with continuous medical monitoring has to be strengthened to better manage the complex long term disease process.

[1] Grundy SM, Pasternak R, Greenland P, Smith S & Fuster V, 1999, Assessment of Cardiovascular Risk by Use of Multiple-Risk-Factor Assessment Equations, J Am Coll Cardiol (1999), 34, 1348 –1359 [18.06.2005*, online] Available: http://www.acc.org/clinical/consensus/risk/risk1999.pdf

[2] American Diabetes Association, 1998, Management of dyslipidemia in adults with diabetes, Diabetes Care, 21, 179–82.

[3] National Institutes of Health, 1997, The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, National Institutes of Health, National Heart, Lung, and Blood Institute; 1997. NIH publication 98–4080.

[4] Beaulieu MD, Talbot Y, Jadad AR & Xhignesse M, 2000, Enhancing prevention in primary care: are interventions targeted towards consumers’ and providers’ perceived needs? Health Expect (2000), 3, 253-62.

[5] Van Steenkiste B, van der Weijden T, Stoffers HE & Grol R, 2004, Barriers to implementing cardiovascular risk tables in routine general practice. Scan J Prim Health Care (2004), 22, 32-7.

[6] Ärzte Zeitung, 2004, Hausarzt-Vize Sturm begrüßt EDV-Hilfe bei Risikoabschätzung [29.07.2004* on-line]. Available: http://www.aerztezeitung.de/docs/2004/06/30/120a0501.asp

[7] Merz CN, Buse JB, Tuncer D & Twillman GB, 2002, Physician attitudes and practices and patient awareness of the cardiovascular complications of diabetes, J Am Coll Cardiol (2002), 40, 1877-81.

[8] Altenhofen L, Haß W, Oliveira J & Brenner G, 2002, Modernes Diabetes-management in der ambulanten Versorgung. Köln: Deutscher Ärzte-Verlag.

[9] Merz CN, Buse JB, Tuncer D & Twillman GB, 2002, Physician attitudes and practices and patient awareness of the cardiovascular complications of diabetes, J Am Coll Cardiol (2002), 40, 1877-81.

[10] Heuer H, Heuer S & Lennecke K, 1999, Compliance in der Arzneitherapie. Stuttgart: Wissenschaftliche Verlagsgesellschaft mbH.

[11] Strian F, Hölzl R & Haslbeck M, 1988, Verhaltensmedizin und Diabetes mellitus, Psychologische und verhaltenspsychologische Ansätze in Diagnostik und Therapie. Berlin, Heidelberg, New York, London, Paris, Tokyo: Springer-Verlag.

[12] Weber E, 1982, Problematik der Befolgung therapeutischer Maßnahmen aus klinischer Sicht, p. 33-35, in B Fischer & S Lehrl (edts.), Patient-Compliance, Stellenwert bisherige Ergebnisse, Verbesserungsmöglichkeiten, zweite Klausenbacher Gesprächsrunde. Mannheim: Studienreihe Boehringer Mannheim.

[13] Petermann F, 2000, Compliance und Selbstmanagement, Managed Care, 6, 11-13.

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