Diabetes is a chronic, multisystemic disease requiring a complex management regimen; it is also a self-care disease in which patient behavior is the most critical determinant of outcome. These characteristics create a poor fit for diabetes in the U.S. health care delivery system that is primarily designed to handled acute and episodic illness. The nonreimbursable nature of most diabetes care, the lack of primary care physician time to deal with the several aspects of diabetes, and the chronic nature of this disease result in significant undertreatment of most patients with diabetes. To address these problems, we are proposing exploration of a public health approach to the comprehensive management of diabetes and have evoked the preventive medicine aspect of that field. To demonstrate the effectiveness and social value of a public health approach to diabetes, we plan to conduct community-based Diabetes Evaluation and Education Clinics (DEECs) in 5 Michigan communities, 2 large and 3 small, that will offer a comprehensive assessment of all aspects of the diabetic status of about 100 patients per year. By random assignment, half of the patients so evaluated will subsequently receive a comprehensive intervention addressing each aspect of the assessments made. All patients seen at the DEECs will be evaluated on two global scales, a Diabetes Outcome Scale (DOS) and a Diabetes Care Scale (DCS) whose components and weighing will be determined by a national panel of diabetologists using the Delphi procedure. Annual reassessment of patients in both arms of the study should provide documentation that those patients randomized to the intervention arm of the study derived a documentable benefit that significantly exceeds the cost of the interventions. The results of this study should portray the value such future clinics might have for public health policymakers, health insurance administrators, and the Federal Government. If successful, Diabetes Evaluation and Education Clinics operated by local health agencies could be a significant adjunct to the health care delivery system currently struggling to provide the comprehensive care that diabetes require. Such a system will be greatly needed if the results of the Diabetes Control and Complications Trial (DCCT), due to be announced in June, 1994, are positive. If the DCCT is positive, the current health care delivery system would be unable to replicate the DCCT advantage to the large number of diabetic patients who might benefit from it. This project is one of the ways in which the MDRTC is preparing for the announcement of the results of the DCCT, as the NIDDKD has requested we do.
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