[Structured treatment and teaching programs and an improvement in private health care lead to a better quality of diabetes care. JEVIN, a population-based trial 1989/90 up to 1999/2000].
AIMS AND HYPOTHESES: JEVIN ( Jena's St. Vincent Trial) is a prospective, 10-year follow-up, population-based survey of all insulin-treated patients with type 1 and type 2 diabetes mellitus aged 16-60 years and living in the city of Jena (100,000 inhabitants), Thuringia. It aims to show the effects of recent changes in the health care system and new treatment strategies. During the period from 1989/90 to 1994/95, the health care system was decentralized. There has been an broad implementation of postgraduate educational courses for primary care physicians, of structured treatment and teaching programs (TTP), of intensified insulin therapy, and blood glucose self-monitoring for all patients.


METHODS
190 patients (83% of the target population), 244 patients (90%) and 261 patients (90%) were studied in 1989/90, 1994/95 and 1999/2000, respectively.


RESULTS
Up to 1994/95, the relative HbA(1c) (HbA(1c)/mean normal) of patients with type 1 diabetes increased (1994/95: 1.65 +/- 0.35 vs. 1989/90: 1.52 +/- 0.31; p = 0.002). For patients with type 2 diabetes mellitus it remained constant (1.75 +/- 0.4 vs. 1.78 +/- 0.31; p = 0.669). During the period from 1994/95 to 1999/2000, there was a substantial improvement in the relative HbA(1c) of both, patients with type 1 (1.48 +/- 0.3; p < 0.0001), and type 2 diabetes (1.47 +/- 0.25; p < 0.0001). Up to 1999/2000, 87.7% of the patients with type 1 (1989/90: 0%, 1994/95: 73.2%) and 96.6% of the patients with type 2 diabetes (1989/90: 0%, 1994/95: 89.7%) participated in TTPs. Similarly, the percentage of patients with intensified insulin therapy (type 1/2: 1989/90: 5.3%/3.4%, 1994/95: 80.3%/30.8%, 1999/2000: 94.7%/48.3%) and the frequency of weekly blood glucose self-monitoring (type 1/2: 1989/90: 1 [0-28]/0 [0-21], 1994/95: 25 [0-49]/14 [0-35], 1999/2000: 28 [0-70]/21 [0-46]) increased. Moreover, there was a drastic improvement in private health care: up to 1999/2000, about 90% of all the patients studied were treated by primary care physicians who took part in postgraduate educational courses.


CONCLUSIONS
During the past decade, there has been a substantial improvement in the quality of diabetes control. The broad implementation of structured TTPs, intensified insulin therapy, and blood glucose self-monitoring for patients with type 1 and 2 diabetes mellitus seem to be the major cornerstones for the improved quality of diabetes care. However, the impressive improvement in the quality of diabetes care in patients with type 2 diabetes mellitus seems not to be related mainly to an increase (about 10% vs. 20% in type 1 diabetes) in the number of patients under specialist care, but rather to an improvement in the quality of diabetes therapy administered by private health care physicians.
Schiel
Ralf
R
Klinik für Innere Medizin III, Friedrich-Schiller-Universität Jena. ralf.schiel@med.uni-jena.de
Müller
Ulrich A
UA
D000284:Administration, Oral; D000293:Adolescent; D000328:Adult; D015190:Blood Glucose Self-Monitoring; D003627:Data Interpretation, Statistical; D003920:Diabetes Mellitus / Q000097:blood / Q000628:therapy*; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000628:therapy; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000628:therapy; D004502:Education, Medical, Continuing; D005500:Follow-Up Studies; D005858:Germany; D006442:Glycated Hemoglobin / Q000032:analysis; D006801:Humans; D007004:Hypoglycemic Agents / Q000008:administration & dosage / Q000627:therapeutic use; D007328:Insulin / Q000008:administration & dosage / Q000627:therapeutic use; D008875:Middle Aged; D010353:Patient Education as Topic; D011320:Primary Health Care / Q000592:standards*; D011446:Prospective Studies; D011787:Quality of Health Care; D013997:Time Factors
D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents; D007328:Insulin