Introduction 

Diabetes, the sixth leading cause of death in the United

States, is a chronic disease characterized by persistent

hyperglycemia (high blood glucose levels). Left untreated,

diabetes can cause serious complications affecting the

circulatory and nervous systems, kidneys, eyes, and feet. 

Even though the proper treatment of diabetes can be

complex, biomedical research has demonstrated in model

settings what can be achieved clinically. Therefore, health

services research funded by the Agency for Healthcare

Research and Quality (AHRQ) has built on such results to

learn more about what can be achieved when treating

diabetic patients in a typical office practice. However, there

are limits beyond which the data from biomedical trials

cannot be extrapolated to the typical office practice because

of differences between sample populations selected for such

trials and the general patient population. This synthesis

provides good evidence to show that intensive therapy using

a team approach is an effective way to reach the major

goals of diabetes therapy: lowering glucose (blood sugar) to

appropriate levels and avoiding or postponing the onset of

serious complications.

The following discussion is intended to provide health care

professionals with information they can use in their

practices to assist them in providing better care and helping

their patients to become better self-managers. 

Background

An increasing number of Americans have diabetes—

approximately 16 million as of 1999—and diabetes costs

society close to $100 billion per year in medical and

nonmedical costs. In 2001, almost 800,000 people will be

diagnosed with the disease and close to 200,000 will die

from its complications. Furthermore, the burden of diabetes

is considerably higher for the elderly and minorities than

the general population.1

In a healthy person, blood sugar levels, which fluctuate

based on food intake, exercise, and other factors, are kept

within an acceptable range by insulin. Insulin, a hormone

produced by the pancreas, helps the body absorb excess

sugar from the bloodstream. In a person with diabetes,

blood sugar levels are not adequately controlled by insulin.

Physicians monitor glycemic levels by using the

hemoglobin (Hb) A1c test, which shows the average amount

of sugar in the blood over the preceding 3 months. In

Improving Care for Diabetes Patients Through Intensive 

Therapy and a Team Approach

Summary

• A study of over 8,000 patients with type 2 diabetes found

that, 2 years after the initiation of insulin, more than 60

percent of the patients still had blood sugar levels of

over 8 percent (HbA1c).

• A survey of providers found that there are many barriers

to achieving treatment goals, including the frequently

asymptomatic character of diabetes, the involvement of

many body systems, and difficulties in altering lifestyle.

• Another study found that, after 12 months, 87 percent of

patients (80 percent with type 2 diabetes) achieved good

control of blood sugar (8 percent or less HbA1c) by the

use of complex treatment regimens and a team

approach, with many patients receiving either two oral

hypoglycemics or one oral hypoglycemic plus insulin

injections.

• Patients can achieve good diabetic control if providers

recommend intensive therapies, use a team approach,

furnish appropriate preventive care, and put into

practice proven strategies that help patients better

manage their care.

RESEARCH IN ACTION

Agency for Healthcare Research and Quality • www.ahrq.gov

Issue #2 November 2001
healthy persons, glycemic values as measured by HbA1c

levels are in the 4-6 percent range, according to the

American Diabetes Association (ADA).a The ADA

guideline for diabetic patients is <7 percent.2 There are two

major types of diabetes.b Type 1 is an autoimmune disease

in which the ability of the pancreas to make insulin has

been destroyed. Type 1 diabetes usually develops in

children or adults under age 30, but it can occur in older

individuals. In type 2 diabetes, the pancreas produces some

insulin, sometimes even large amounts; however, either the

pancreas does not produce enough insulin or the body’s

cells are resistant to the action of insulin. Between 90 and

95 percent of diabetes patients have type 2 diabetes, which

mostly affects adults over age 40. The incidence of this

type of diabetes is rising rapidly; increasingly type 2

diabetes is appearing in patients in their 30s and younger.3,4

Providers say that diabetes is a difficult disease to treat

because—

• It is closely related to patient behaviors that require

complex interventions and persistent efforts to change

(sedentary lifestyle, poor diet, and obesity).

• Patients may have the disease for years without knowing

it, and even after diagnosis may remain asymptomatic,

with the result that they are less motivated to make

needed lifestyle changes.

• Patients need to actively manage the disease through

diet, exercise, self-monitoring, and medicating, even in

the absence of symptoms.

• Providers may need to coordinate interventions with

different specialists.

Providers evaluate a patient’s blood sugar levels both by

glucose measurements and by the HbA1c test. In contrast,

the patient’s self-monitoring of blood glucose shows the

level of blood sugar only at the time of measurement. 

Biomedical research shows positive outcomes under

ideal conditions

Until the last decade, there was some controversy in the

medical community regarding the relationship between

careful control of blood sugar and delaying or preventing

complications such as eye and kidney disease and vascular

complications for people with diabetes. However, the

United Kingdom Prospective Diabetes Study (UKPDS) for

type 2 diabetes and, in the United States, the Diabetes

Control and Complications Trial (DCCT) for type 1

diabetes have demonstrated that any reduction in blood

sugar (as measured by HbA1c) is likely to reduce the risk of

complications.5,6 These long-term trials, conducted under

closely supervised clinical conditions and using newly

diagnosed volunteer subjects, found that intensive therapy

could achieve effective glycemic control and postponement

of major complications over a period of many years. 

In the UKPDS, 5,000 newly diagnosed type 2 diabetes

patients first attended several sessions of dietary education

given by physicians and dietitians and were treated with

diet therapy for 3 months before receiving other treatment.7,8

They were then randomly assigned to four groups. Each of

the three “intensive therapy” groups received a single

medication (chlorpropamide, glyburide, or insulin); the

fourth group, a control group, received a special diet only.

However, the single medication therapy in the intensive

therapy groups failed to achieve tight glycemic control,

making it necessary to institute combination drug therapy

(using insulin or metformin along with one of the other two

drugs). 

Median HbA1c levels over a 10-year period were 7.0

percent for the intensive therapy groups compared with 7.9

percent for those receiving conventional treatment.

Additionally, complication rates were significantly lower

for the intensive therapy groups compared to the

conventional therapy group—33 percent lower for end stage

renal disease and 17 percent lower for retinopathy. 

In the DCCT, 1,441 type 1 diabetes patients were assigned

to one of two groups.6 The first group received intensive

insulin therapy, either by external insulin pump or by

receiving three or more daily insulin injections. The second

(control) group received conventional therapy (one or two

daily insulin injections). Patients in the first group

monitored their blood sugar four times each day and, when

necessary, made daily adjustments to their dosage levels.

As part of their therapy, they made monthly visits to a

health care team composed of a physician, nurse educator,

dietitian, and behavioral therapist. Each patient was given a

diet and exercise plan and was contacted weekly by a

member of the team to review and adjust the treatment

2 www.ahrq.gov

a

The percentages for normal values may vary somewhat, depending on

the authority being cited.

b

There are also two other types of diabetes: “gestational diabetes,” which

affects pregnant women, and “other specific types,” resulting from

specific genetic syndromes, surgery, drugs, malnutrition, infections, and

other illnesses.
regimen. Patients in the control group did daily selfmonitoring of urine or blood but did not usually make daily

adjustments to their dosage levels. These patients also

received education about diet and exercise but were seen

only every 3 months. Over a period of 6.5 years, the

intensive therapy group had average HbA1c levels (at 7.2

percent) and rates of diabetic complications significantly

lower than the control group.c

A third study found that patients not only avoid

complications, but also feel better, even over the short term,

when their glucose levels are closer to normal. In this

study by Harvard University researchers, patients received

intensive drug therapy over a 12-week period. During the

study period, patients were closely monitored at nine

different times using clinical and laboratory evaluations.

The patients received glipizide (an oral medication) in

doses that were adjusted upward during the first part of the

study in order to achieve appropriate glycemic control. The

Harvard study found that the patients with mild to

moderate type 2 diabetes receiving glipizide plus diet

modification, when compared to a control group receiving

a placebo plus diet modification, had better glycemic

control (7.5 percent vs. 9.3 percent HbA1c) and enjoyed

substantial short-term symptomatic and quality of life

(QOL) benefits.9 Patients showed significant improvement

on four of five QOL scales (symptom distress, general

perceived health, cognitive functioning, overall visual

acuity scale). On the fifth scale, mental and emotional

health, there were no statistically significant changes.

Health services research studies show varied

success in controlling blood sugar

Studies funded by AHRQ have used more broadly

representative groups of patients with diabetes than either

the DCCT or the UKPDS. The median patient age in the

largest AHRQ study was 65, compared to a median age of

www.ahrq.gov 3

• Variations in the Management and Outcomes of Diabetes, 1990-97. New England Medical Center. Measured the effectiveness of existing

clinical care in controlling blood sugar and avoiding or postponing complications. Showed that help from family members increases

elderly diabetics’ adherence to treatment and dietary regimens. 

• Center for Medical Treatment Effectiveness Programs, 1997-98. Case Western Reserve University Henry Ford Health System. Developed,

evaluated, and implemented culturally appropriate partnerships among patients, health care providers, and the community. Showed that

social support increases African-American diabetic patients’ adherence to treatment and dietary regimens. 

• Mexican-American Treatment Research Center, 1992-98. University of Texas Health Sciences Center. Studied the effectiveness of existing

treatments for chronic disabling conditions in Mexican Americans. Identified the existence of substantial barriers for both providers and

patients in implementing accepted treatment guidelines.

• Improving Primary Care of African-Americans with NIDDM, 1998-2002. Emory University. Evaluates provider support strategies for the

management of non-insulin-dependent diabetes mellitus (NIDDM). Identified barriers to provider adherence to management goals.

Showed how an intensive approach to therapy (including patients taking more than one medication, a team of providers, and more

frequent interactions between patients and clinicians) achieved therapeutic success. 

• Automated Assessments and the Quality of Diabetes Care, 1999-2003. Palo Alto Institute for Research and Education. Evaluates whether

innovations in information technology can increase patient/provider interactions and assist patients in self-management. Will examine

variation in outcomes for patients with diabetes by using an automated telephone disease-management system to assess patients weekly

for 1 year.

AHRQ-Funded Research on Diabetes Care 

c

The mean value for all glucose profiles was 155 + 30 mg per deciliter in

the intensive therapy group vs. 231 + 55 mg per deciliter in the control

group. For the intensive therapy group, the rate of complications was 76

percent lower for the onset of retinopathy, 54 percent lower for

albuminuria, and 60 percent lower for the appearance of neuropathy.
53 in the UKPDS; older patients are more likely to have

other comorbidities or complications from diabetes. These

AHRQ-funded studies have shown that providers and

patients may achieve only partial success in bringing blood

sugar levels down to recommended levels and performing

recommended examinations. For example, three AHRQfunded studies evaluating diabetes care found that glycemic

control was achieved for no more than 50 percent of the

patients. They are summarized in Table 1. 

The largest study examined what happened to the blood

sugar levels of a large group of diabetic patients after

primary care physicians started to treat them with insulin.10

Most of these patients had previously been taking oral

hypoglycemic medications. After 2 years, more than 60

percent of the patients in the study still had blood sugar

levels of over 8 percent (HbA1c). 

A second AHRQ-funded study evaluated internal medicine

residents’ treatment of African-American diabetic patients

in a hospital ambulatory care setting.11 This study found

that 51 percent of patients on oral medications and 47

percent of patients on insulin did not reach the

recommended treatment goal for the study (an HbA1c level

of less than 8 percent). It also found that on five tests

recommended by the American Diabetes Association

(dilated eye exam, lipid exam, home glucose monitoring,

foot exam, and urine protein screen), practice levels fell

short of national standards.

The third AHRQ-funded study looked at the outcomes of

170 mild to moderately ill diabetic patients treated by

endocrinologists, family practitioners, and general

internists.12 In general, after 2 years of treatment,

researchers found no meaningful differences in HbA1c

levels or other health outcomes between patients of

endocrinologists and patients of family practitioners and

general internists. It is unclear whether similar results

would occur if severely ill patients were studied. 

4 www.ahrq.gov

Persons Affected

• 15.7 million people (5.9 percent of the U.S. population) 

• 6.3 million (18.4 percent ) of the elderly (65 and over)

• 8.2 percent of people 20 and over 

• 10.8 percent of non-Hispanic blacks, 10.6 percent of Mexican-Americans, and 9.0 percent of American Indians 

• From 1990 to 1998, diabetes increased by 70 percent for people ages 30 to 39, by 40 percent for people ages 40 to 49, and by 31

percent for people ages 50 to 59.

Human Costs

• 798,000 new cases diagnosed per year

• 193,000 deaths (1996)

• 12,000 to 24,000 new cases of blindness each year due to diabetic retinopathy

• 27,000 cases of end stage renal disease (1995)

• 67,000 amputations per year (1993-95)

Financial Costs

• $98.2 billion per year: 

$44.1 billion in medical costs 

$54.1 billion in indirect costs (work loss, disability, and premature death)

Sources: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disorders. Diabetes Statistics of the United States, Nov. 1, 1998; Centers for Disease

Control and Prevention Web site: < cdc.gov/diabetes/pubs/facts98.htm>; American Diabetes Association. Direct and Indirect Costs of Diabetes: <diabetes.org/>; Mokdad AH, Ford ES,

Bowman BA, et al. Diabetes trends in the U.S.: 1990-1998, Diabetes Care 2001; 23(9):1278-83.

Important Facts About Diabetes
Providers and patients experience barriers to

meeting treatment goals

Both providers and patients encounter many barriers that

prevent them from achieving established treatment goals.

AHRQ has funded studies to understand the barriers that

physicians cite for difficulties in achieving therapeutic

goals. These barriers, summarized in Table 2, frequently

were related to the complexity of the patients’ condition and

the difficulties in ensuring patient adherence, and they may

have additional implications.13,14 For example, when

diabetic complications begin to affect different body

systems and a variety of specialists become involved in

treating the disease, primary care providers may find it

difficult to ensure that treatment protocols are followed. 

Underscoring provider perceptions of patient barriers to

care, an AHRQ-funded study looking at how diabetic

patients respond to physician recommendations found that

patients were much less likely to follow recommendations

about diet (69 percent) and exercise (19 percent) than they

were to follow medication regimens (91 percent).15 The

www.ahrq.gov 5

Table 1. Physician specialty and glycemic control: Summary findings

Study Subjects Physician specialty Glycemic levels

Hayward RA, Manning WG, 8,868 type 2 diabetics Generalist physicians 2 years after initiation of insulin:

Kaplan SH, et al. Starting • Over 60 percent of patients

insulin therapy in patients were >8 percent

with type 2 diabetes. JAMA 

1997; 278(20):1663-9

Bernard AM, Anderson L, 140 diabetics (31 type 1, Internal medicine After 12 months:

Cook CB, et al. What do 109 type 2) residents • 50 percent of patients

internal medicine residents were >8 percent

need to enhance their diabetes 

care? Diabetes Care 1999; 22(5):

661-6

Greenfield S, Rogers W, 170 type 2 diabetics After 2 years, all patients averaged:

Mangotich M, et al. Outcomes of General internists .............. 9.7 percent 

patients with hypertension and Family physicians ............. 9.3 percent 

non-insulin-dependent diabetes Endocrinologists ............... 9.3 percent

mellitus treated by different 

systems and specialties. Results 

from the Medical Outcomes Study. 

JAMA 1995; 274(18):1436-44

Note: According to the American Diabetes Association, an HbA1c value of 4-6 percent is considered normal. This value is an approximation and may vary depending upon expert opinion.

Table 2. Summary of barriers to treatment goals

Physican barriers:

• Diabetes affects many body systems

• Controversies about proper diagnosis and treatment

• Uncertainty of prognosis

• Lack of time

• Clinical inertia

Patient barriers:

• The frequently asymptomatic character of diabetes

(removing an important incentive for self-care)

• Necessity of daily patient interventions 

• Need to alter lifestyle (primarily diet and exercise patterns) 

• Acute illness

• Hypoglycemia due to treatment

• Patient refusal to follow provider recommendations

• Lack of patient educational materials

Sources: Larme AC, Pugh JA. Attitudes of primary care providers toward diabetes.

Barriers to guideline implementation. Diabetes Care 1998; 21(9):1391-6; El-Kebbi IM,

Ziemer DC, Gallina, DI, et al. Diabetes in urban African-Americans. XV. Identification of

barriers to provider adherence to management protocols. Diabetes Care 1999;

22(10):1617-20. 
researchers suggested that the reasons for poor adherence to

lifestyle recommendations could include public awareness

of controversy over the validity of recommendations, belief

that physicians can sometimes be wrong, belief that

physician instructions can be ignored, and the difficulty of

incorporating new behavior into their daily lives.

Combination of intensive therapy and team

approach promotes good outcomes

Even though the treatment of diabetes is complex and

major barriers to achieving good outcomes exist, AHRQfunded research has shown that glycemic control can be

achieved and complications of diabetes postponed through

a combination of intensive drug therapy and a team

approach. (See Table 3.) In a retrospective study, academic

endocrinologists in Atlanta examined the clinical records of

151 diabetes patients (121 with type 2 diabetes and 30 with

type 1) in their own practice.16 Most of these patients had

complications as a result of their diabetes, including

peripheral neuropathy (78 percent), retinopathy (22

percent), hypertension (80 percent), hyperlipidemia (64

percent), coronary heart disease (27 percent), and

peripheral vascular disease (14 percent)–not unusual for

patients who had had diabetes, on average, for 12 years.

Investigators found that half the patients made at least four

visits during the study year. Patients alternated between

visits that included both a physician and a nurse practitioner

and visits with a nurse practitioner alone. Nurse

practitioners, who were also directly available at other times

for phone contact, were able to facilitate more frequent

adjustment of therapy when necessary. The average HbA1c

of patients with type 2 diabetes was 6.9 percent; 87 percent

achieved good control of blood sugar (8 percent or less

HbA1c) by the use of complex treatment regimens, 78

percent were managed with more than diet alone or a single

oral agent, and many patients received either two oral

hypoglycemics or one oral hypoglycemic plus insulin

injections. The average HbA1c of patients with type 1

diabetes was 7.1 percent; 80 percent achieved good control

of blood sugar with an average of 3.4 injections of insulin

per day. (See Figure 1.) In addition, screenings were

performed at recommended intervals for major

complications, including eye and foot problems, high lipid

levels, and hypertension. 

The Atlanta researchers reviewed several earlier studies that

focused mostly on patients in primary care settings and

found that significant percentages of patients had HbA1c

levels above 8 percent.17,18 When comparing their own

study to one of these earlier studies,19 the AHRQ-funded

Atlanta team found that patients in their study were more

likely than those in the earlier studyd to be using oral

hypoglycemic medications plus insulin (31 percent vs. 3

percent). Also, the Atlanta patients taking insulin were

more likely to be injecting three or more times per day (42

percent vs. 4 percent). 

6 www.ahrq.gov

Table 3. Components of intensive therapy and a team approach in treatment of diabetes

• More frequent use of 2 oral medications (a hypoglycemic and an antihyperglycemic) or 1 oral medication plus insulin

• Greater likelihood of 3 or more daily injections for insulin recipients

• 4 or more visits per year for many patients

• Visits with both physicians and nurse practitioners alternating with visits with a nurse practitioner

• Direct telephone availability of nurse practitioners

• Dietitian visits with patients

• Screening for complications

• Self-monitoring

Source: Adapted from Miller CD, Phillips LS, Tate MK, et al. Meeting American Diabetes Association guidelines in endocrinologist practice. Diabetes Care 2000; 23(4):444-8.

d

This study was based on persons with diabetes in the Third National

Health and Nutrition Examination Survey (NHANES III). In this study,

participants who received either oral hypoglycemics or insulin had

average HbAlc levels of 8.0 percent of above.
The Atlanta researchers stated that “the discrepancies

between our data and those of primary care studies

(showing less success in achieving glycemic control) may

be because of factors other than the type of treating

physician.”16 The following factors were mentioned by the

researchers: 

• The earlier primary care studies date from the early

1990s and may not reflect current practices.

• Patient motivation may have differed. 

• A broader array of medications was available at the time

of the Atlanta study. 

• The ability to do rapid on-site HbA1c measurements was

available for the Atlanta physicians. 

The researchers emphasized that “good glycemic outcomes

are attributable to a commitment to achieving normal

metabolic status that is reinforced through multiple

contacts, including not only physician appointments but

also nurse practitioner visits, dietitian visits, and telephone

calls.”16

In a study describing the results of diabetes therapy for type

2 patients in their own clinic, the Atlanta-based research

team identified “clinical inertia” (not intensifying therapy

when glycemic levels are high) as a barrier to care in a

small group of cases (40 visits, or 6 percent, out of 636

visits). This phenomenon occurred either because patients

were not adhering to their meal plan or for no stated

reason.20 A related study, by the same researchers, found

that clinical inertia could be reduced by the use of a stepsequence treatment intensification plan. The sequence of

steps started with diet alone, advanced to the medications

glyburide or glipizide, and then added insulin in varying

strengths and frequencies of administration. The study,

conducted from 1992 to 1996, found that when providers

used this sequence of steps, the percentage of type 2

diabetes patients with good glycemic control (an HbA1c of

<7 percent) increased from under 40 percent to close to 60

percent over a 12-month period.21 The researchers

considered these results even more significant since they

were achieved in an underserved minority population

(urban African-Americans) that tends to have poor rates of

glycemic control and high rates of diabetic complications.

As part of the study, the researchers emphasized to

providers that patients were to remain in a given treatment

category only if their glycemic control was good. 

Preventive care can help to postpone or avoid

complications

Diabetes can lead to partial or total blindness as a result of

proliferative retinopathy, a complication that occurs when

new blood vessels that grow to replace older defective ones

leak blood into the retina. Blindness can also result from

macular edema, a complication that occurs when blood

vessels in the eye balloon and malfunction, leading to a

swelling of the retina. 

In order for vision-related complications to be treated

promptly, the American Diabetes Association recommends

that diabetic patients have comprehensive periodic dilated

eye and vision examinations by an ophthalmologist or

optometrist.2 An AHRQ-funded study reinforces these

recommendations. Researchers, using a computer model,

estimated that screening and prompt treatment for eye

disease in all appropriate patients with type 2 diabetes, by

virtually eliminating severe vision loss for patients with

proliferative diabetic retinopathy and macular edema,

would preserve the sight of thousands of diabetic patients.22

Nearly all of the benefits would come from the early

detection and prompt treatment of macular edema in

patients whose type 2 diabetes began before age 45. 

www.ahrq.gov 7

<7 >7 and <8 >8 and <9 >9

0

10

20

30

40

50

60

70

Percent

Type 2 Type 1

61%

57%

26%

23%

9% 10%

4%

10%

Figure 1. Glycemic values for patients in the Atlanta

study by type of diabetes

Source: Miller CD, Phillips LS, Tate MK, et al. Meeting American Diabetes Association

guidelines in endocrinologist practice. Diabetes Care 2000; 23(4):444-8.
Provider questionnaires improve adherence to

treatment protocols

Other strategies oriented toward assisting the provider can

help patients receive needed care. An AHRQ-funded study

showed that one way in which providers increased their

ability to follow protocols was through completing

questionnaires that served as a self-survey about the

appropriateness of glycemic goals and whether their

patients were well controlled.14 Both physicians and nurses

were asked to fill out one-page multiple-choice

questionnaires after each office visit over a 3-month period.

In this study, conducted at a diabetes clinic treating AfricanAmerican patients, adherence to protocols calling for

intensification of therapy when indicated (e.g., putting

patients previously treated by diet alone on medication or

adding sulfonylurea medication to insulin) increased from

55 percent to 63 percent when providers completed a

questionnaire after every patient visit.

This study is part of a series of ongoing AHRQ projects

that will be providing further evidence about other

interventions to assist providers in rendering effective care.

Two interventions being tested include: (1) the use of

computerized reminders and flow sheets to track blood

sugar levels, performance of tests, and test results for each

of a provider’s diabetic patients and (2) face-to-face

discussions between primary care providers and

endocrinologists to review patient management.

Barriers to patient adherence can be reduced

As discussed earlier (Table 2), both providers and patients

have identified barriers that prevent patients from following

the advice given to them about their treatment. Research

funded by AHRQ and others can assist providers in helping

their patients to overcome some of these barriers. For

example, studies have shown that social support networks

help elderly patients and African-American adults to

comply with certain recommended practices.23,24 Also,

automated telephone disease management (ATDM) with

nurse followup has been found to be a successful strategy

for helping diabetic patients manage their care.25 ATDM

increased the number of patients who achieved glycemic

control and avoided diabetic symptoms. In addition, a new

program aimed at primary prevention in minority children

at risk for developing diabetes has shown promise in one

study.26 Finally, a chronic disease self-management

program developed for chronic conditions other than

diabetes and now being used in a number of diabetes clinics

around the country may yield positive results for diabetic

patients.27

Social support assists vulnerable populations in

improving adherence

An AHRQ-funded study of family members of persons

with diabetes age 70 and over found that more than onethird went with older diabetics on their doctor visits. In

addition, 22-50 percent of family members reported helping

with various aspects of diabetes care, with the top two

categories being “keeping enough medication on hand” and

“following a diet.”23 Such participation, as well as help with

the daily management of diet and medications, was more

likely if the patients were functionally disabled.

Researchers found that those patients who received more

family assistance were more likely both to take their

medications as prescribed and to follow their diets.

Another AHRQ-funded study, a literature review of studies

reporting on the effects of social support among AfricanAmerican adults with diabetes, found that AfricanAmericans relied more heavily than whites on informal

social networks to meet their disease management needs.24

The social support consisted of help with the day-to-day

management of diabetes, including:

• Help with diet supervision.

• Medication assistance.

• General support. 

• Blood sugar monitoring.

• Foot care.

In findings that parallel the study on social support and the

elderly,23 the review found that social support is

significantly associated with improved diabetes

management among this population. 

Automated telephone disease management (ATDM)

improves patient outcomes 

An AHRQ-funded literature review of studies on the effects

of interactive voice response systems in the diagnosis and

management of chronic disease found that these systems

can positively affect health and health behavior outcomes.25

In a randomized controlled trial, 272 diabetic patients in the

Department of Veterans Affairs (VA) health system received

8 www.ahrq.gov
biweekly calls from an automated telephone-messaging

computer that enabled patients to provide a recorded

assessment of their health status and health behaviors in 5-8

minutes. Patients used their phone’s touch-tone keypad to

report self-monitored blood glucose readings and various

symptoms. Based on the automated assessment reports, a

nurse made followup calls to address reported problems.

The patients who received ATDM calls with nurse

telephone followup had better glycemic control and selfcare along with fewer diabetic symptoms than patients who

did not receive these calls.28 After a 12-month trial period,

among patients with HbA1c values above 9 percent, the

average values were 9.1 percent for those receiving ATDM

calls and 10.2 percent for those who did not. The entire

group receiving ATDM calls had HbA1c levels at followup

that were 0.3 percent lower than those of the control group

(8.1 percent vs. 8.4 percent). The researchers estimated that

if the reduction in glycemic values achieved in this study

could be replicated throughout the VA system, the

government could save $100 million each year. The results

of this study replicated those from a previous ATDM trial

conducted among English- and Spanish-speaking patients

in county clinics. In that study, the investigators found that

ATDM improved patients’ glycemic control, symptoms, and

self-care, and decreased depressive symptoms.29

Primary prevention can lower risk factors for

Mexican-American children 

To learn more about how to prevent diabetes from

occurring in the Mexican-American population, AHRQ

funded a pilot study of an intervention program for children

at risk for type 2 diabetes.26 The 31/2-month program had a

threefold emphasis on understanding of diabetes, diet, and

exercise and was designed to be culturally and ageappropriate for Mexican-American children. Thirty-seven

at-risk children 7-12 years of age (those with at least one

diabetic parent or grandparent) and their parents were

enrolled in an eight-session educational program intended

to inform them about diabetes and its complications and to

teach the essentials of a healthy lifestyle. Health screenings

for the children were given before and after the program.

Post-program analysis of individual risk factors showed a

trend toward more normal values. For example, the

percentage of children whose consumption of protein, total

fat, saturated fat, and cholesterol fell within the

recommended daily requirement increased. Also, 94

percent of parents and 67 percent of children began reading

food labels, 83 percent of parents began to use fat-modified

recipes, and 83 percent of children began exercising

regularly. Parental involvement also resulted in parents

making progress toward adopting healthier lifestyles. 

Chronic Disease Self-Management Program may

improve adherence

The Chronic Disease Self-Management Program (CDSMP)

is now being used by health organizations in 31 States and

9 countries (including diabetes treatment facilities).27 The

CDSMP could eventually have a significant impact on the

health status and health care use of persons with diabetes.

The program originated in an AHRQ-funded study that

tested a 7-week community-based patient education

program for people with heart disease, lung disease, stroke,

and arthritis. A premise of the program is that many

chronic diseases, such as diabetes, heart disease, lung

disease, arthritis, and high blood pressure, pose similar

problems in patient self-management. The CDSMP focuses

on improving people’s self-efficacy in taking care of their

own health. In the initial 6-month followup, the study

found positive results for self-reported health, disability,

fatigue, and hospital use indicators.

The CDSMP consists of seven weekly 21/2-hour sessions

(later changed to six weekly sessions) focusing on

nutritional change, adoption of exercise programs, use of

medications and community resources, health-related

problem solving, and decision-making.e Preliminary

followup studies (covering a 2-year period) indicate that

participants have improved health, more energy, and fewer

hospitalizations and doctor visits. 

Research is currently underway to improve

diabetes care

AHRQ is continuing its efforts to find the most effective

means of treating diabetes and improving outcomes of care.

Currently, AHRQ-funded researchers are testing new

technologies to improve patient care, enhancing existing

treatment modalities, making care more culturally sensitive,

testing interventions to improve provider performance,

delineating the impact of managed care on patients with

www.ahrq.gov 9

e

For sites using the program for diabetes and other conditions, see

www.Stanford.edu/group/perc.
diabetic retinopathy, and tracing the indirect economic

impact of diabetes. For example, AHRQ funds are being

used to—

• Examine variation in outcomes for diabetic patients

using an automated telephone disease management

system and extend the use of ATDM to Spanishspeaking patients.

• Test the impact of a culturally sensitive multimedia

computer education program in a clinical setting on

diabetes-related knowledge, attitudes, self-efficacy (the

belief that what you do makes a difference), and selfcare for African-American and Latino populations. 

• Measure the effects of increased self-monitoring of

blood glucose on the cost, quality, and outcomes of

diabetes care in patients enrolled in a managed care

program.

• Test a more intensive collaborative approach to disease

management vs. a more traditional approach in 40

midwestern community health centers serving a

medically underserved population in rural and urban

areas. The “collaborative” approach involves intensive,

extended training of providers in total quality

management as well as improvement of skills in

provider-patient communication, as compared to the

“traditional” approach of basic, brief training in total

quality management.

• Test the effect of interpreters on diabetes outcomes for

Navajo patients. 

• Examine methods for helping physicians follow

recommended treatment modalities. 

• Study the organizational and financing arrangements in

managed care and their effects on eye care for workingage patients with diabetic retinopathy. 

• Identify the extent of the indirect costs of diabetes, as

represented by reduced on-the-job productivity. (This is

the first study to consider this type of productivity loss

for diabetes.)

• Pilot-test methods for improving the treatment of lowincome diabetic patients in community health centers 

• Pilot-test methods for developing a claims-based quality

measure for ambulatory diabetic care.

• Study how features of managed care affect outcomes of

patients with diabetes and, in a related study, outcomes

for patients with diabetic retinopathy.

Conclusion 

AHRQ-funded research shows that patients can achieve

good diabetic control if providers recommend intensive

therapies, use a team approach, furnish appropriate

preventive care, and put into practice proven strategies that

help patients better manage their care. Few patients have

type 2 diabetes without other diagnoses.33 Generalists, in

treating multiple chronic illnesses in a single patient, may

balance glycemic control with other interventions in order

to achieve a treatment plan responsive to the most pressing

needs of the patient. The barriers to implementing these

methods and strategies are challenging, but improvements

in patient outcomes are both important and achievable. In

addition, new technologies for assisting the patient in selfmanagement show considerable promise. An example is

customized modules for personal digital assistants

(electronic handheld appliances known as PDAs) for

10 www.ahrq.gov

Diabetes Quality Improvement Project (DQIP)

The Diabetes Quality Improvement Project, a coalition of public

and private entities, has developed a set of diabetes-specific

performance and outcome measures based in part on AHRQfunded research. These new measures, by replacing a number of

current conflicting standards, will allow accurate comparisons of

care within and across health care settings. Once valid

comparisons can be drawn, providers will be able to further

improve care, either by broader use of intensive therapy using a

team approach or by adopting specific innovations that will

assist providers and patients in achieving treatment objectives.

Health care professionals, purchasers of health care, and

consumers are gradually adopting the DQIP measures

nationwide. These measures focus on HbA1c testing, eye and

foot exams, blood pressure control, and monitoring for kidney

disease. 

The DQIP coalition is comprised of seven organizations: the

American Diabetes Association (ADA), the Foundation for

Accountability (FACCT), the Centers for Medicare and Medicaid

Services (CMS, formerly HCFA), and the National Committee for

Quality Assurance (NCQA), the American Academy of Physicians,

the American College of Physicians, and the Department of

Veterans Affairs.30-32
managing diet and exercise. The results of these studies

have set the stage for dramatic improvements needed to

improve care and outcomes for all patients with diabetes. 

For more information

This synthesis was written by Mark W. Stanton, M.A.

(mstanton@ahrq.gov). For further information on diabetes

research, please contact Daniel Stryer, M.D., at

dstryer@ahrq.gov or by telephone at 301-594-4038.

References

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* AHRQ-funded/sponsored research

www.ahrq.gov 11
U.S. Department of

Health and Human Services

Public Health Service

Agency for Healthcare Research and Quality

2101 East Jefferson Street, Suite 501

Rockville, Maryland 20852

www.ahrq.gov

AHRQ Pub. No. 02-0005

November 2001

References (Continued)

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* AHRQ-funded/sponsored research