Evaluation of a Diabetes Management System Based on Practice Guidelines, Integrated Care, and Continuous Quality Management in a Federal State of Germany A population-based approach to health care research ULRIKE ROTHE, MD 1 GABRIELE M¨ ULLER, MPH 1 PETER E.H. SCHWARZ, MD 2 MARTIN SEIFERT, MSC 1 HILDEBRAND KUNATH, PHD, MD 1 RAINER KOCH, PHD 1 SYBILLE BERGMANN, PHD 3 ULRICH JULIUS, PHD, MD 2 STEFAN R. BORNSTEIN, PHD, MD 2 MARKOLF HANEFELD, PHD, MD 4 JAN SCHULZE, PHD, MD 2,5 OBJECTIVE — The aim of this study was to evaluate the Saxon Diabetes Management Pro- gram (SDMP), which is based on integrated practice guidelines, shared care, and integrated quality management. The SDMP was implemented into diabetes contracts between health in- surance providers, general practitioners (GPs), and diabetes specialized 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 begin- ning of 2000 (group A1) and at the end of 2002 (group A2). A subcohort of 105,204 patients was followed over a period of 3 years (group B). RESULTS — The statewide implementation of the SDMP resulted in a change in therapeutic practice and in better cooperation. The median A1C at the time of referral to DSPs decreased from 8.5 to 7.5%, and so did the overall mean. At the end, 78 and 61% of group B achieved the targets for A1C and blood pressure, respectively, recommended by the guidelines compared with 69 and 50% at baseline. Patients with poorly controlled diabetes benefited the most. Preexisting regional differences were aligned. CONCLUSIONS — Integrated care disease management with practicable integrated quality management including collaboration between GPs and specialist services is a significant inno- vation in chronic care management and an efficient way to improve diabetes care continuously. Diabetes Care 31:863–868, 2008 T he growing interest in evidence- based medicine and outcome and a commitment to integrated care across primary and secondary care sectors all contribute to making disease manage- ment an attractive idea (1). The disease management process (1) integrates guide- line application, integrated care, continu- ous quality improvement (2), and patient education (3), but its effectiveness is largely untested, making evaluation essential. There is evidence of regional varia- tions in diabetes management in different primary care settings within the same country (4 – 6). Several structural barriers for integrated care at multiple care levels affect the delivery of high-quality diabetes management (7,8). These barriers are as- cribed to behavioral aspects of patients and health care providers (e.g., unaware- ness of guidelines) or may be system oriented (e.g., fragmentation of the care delivery system) (7,9,10). Implementing managed care structures with a strict fo- cus on integrated care (11–13) may re- duce these barriers (14) while keeping costs under control (15). In 1989 the implementation of the St. Vincent Declaration required the estab- lishment of organized management struc- tures in Europe to improve diabetes care and to reduce the incidence of diabetes complications (16,17). Effective and effi- cient cooperative management structures for diabetes treatment with adequate quality control were crucial because of the complexity of diabetes care. In 1991, Saxon diabetes experts developed the first health care model (diabetes agreement) with the aim of improving diabetes care by establishing diabetes specialist prac- tices (DSPs) (18). In 1994 –1995, the sec- ond diabetes agreement was set up, including quality workshops of GPs, ad- dressing quality management in three cit- ies in the three different administrative ●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●● From the 1 Institute for Medical Informatics and Biometrics, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Dresden, Germany; the 2 Department of Medicine III, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Dresden, Germany; the 3 Institute for Clinical Chemistry and Lab- oratory Medicine, Medical Faculty Carl Gustav Carus, Technical University of Dresden, Dresden, Germany; the 4 Centre for Clinical Studies, Society for Science and Technology Transfer, Technical University of Dresden, Dresden, Germany; and the 5 Saxon Chamber of Physicians, Dresden, Saxony, Germany. Corresponding author: Dr. Ulrike Rothe, Institute for Medical Informatics and Biometrics, Medical Fac- ulty Carl Gustav Carus, Technical University of Dresden, Fetscherstrasse 74, 01307 Dresden, Germany. E-mail: u_rothe@imib.med.tu-dresden.de. Received for publication 3 May 2007 and accepted in revised form 25 January 2008. Published ahead of print at http://care.diabetesjournals.org on 10 March 2008. DOI: 10.2337/dc07-0858. Abbreviations: DSP, diabetes specialized practitioner; GP, general practitioner; OAD, oral antidiabetic drug; SDMP, Saxon Diabetes Management Program. © 2008 by the American Diabetes Association. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact. Clinical Care/Education/Nutrition/Psychosocial Research O R I G I N A L A R T I C L E DIABETES CARE, VOLUME 31, NUMBER 5, MAY 2008 863