Diabetes mellitus is one of the major health problems of the growing elderly population. The overall goal of the Diabetes Care for Order Adults Project (DCOAP) is to develop and test models of care for older adults with diabetes mellitus that can be translated into community practice. The initial phase of the DCOAP was carried out during the current funding cycle of the MDRTC as a randomized clinical trial comparing a program of insulin therapy combined with an intensive education and social support intervention with conventional physician directed patient care management. Preliminary results demonstrate substantial improvement of blood glucose control in the experimental intervention group with no detectable negative effects on patients' quality of life. The proposed activities for the next funding cycle of the MDRTC include follow-up and completion of the initial phase of the DCOAP and will emphasize two new specific objectives designed to aid in the translation of the initial phase of the DCOAP into clinical practice. One project is designed to determine if the successful results of the initial phase of the DCOAP can be replicated using a less resource intense care system that could be realistically adapted in community settings. A randomized clinical trial will be carried out comparing intensive team care management of elderly patients with diabetes, using the initial phase DCOAP model, with patient management by a diabetologist supported only by a standard hospital outpatient diabetes education program. If comparable outcomes are obtained, a key economic barrier to community translation of an intensive management program for older adults with diabetes mellitus will be eliminated. Because our experience with the initial phase of the DCOAP indicated that there is a substantial number of older adults with diabetes mellitus who are unwilling or unable to participate in an intensive treatment program emphasizing use of insulin, a second project is proposed to determine whether a management program which is based on patient-directed behavioral change and which minimizes use of insulin can improve blood sugar control in older adults with diabetes mellitus. To address this objective, a second randomized clinical trial will be carried out to compare outcomes of elderly diabetic patients participating in a management program based on patient-directed behavioral change with those of a control group of patients receiving standard care. Successful completion of the initial phase of the DCOAP plus the two new proposed translation projects will provide the basis for establishment of effective management strategies for older adults with diabetes mellitus that can be implemented in community practice.
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