Outpatient Diabetes Management and the Chronic Care Model

Abstract

The first diabetes clinics were established in North America and Europe following the discovery of insulin with the main objective of teaching patients the technique and principles of its use. Patients with diabetes were mostly treated in hospitals by specialists, but the increasing prevalence of type 2 diabetes made this unpractical. Failure of overwhelmed hospital clinics prompted the creation of “small clinics of general practice” where general physicians were organized to assist small groups of patients to stop the flow of patients toward hospital-based clinics. Since the 1980s, it was shown that diabetes care delivered by organized general physicians achieved similar levels of glycemic control to the one reached in hospital clinics. Diabetes centers evolved from hospitalization of all new patients, and ambulatory care became the norm. Randomized controlled trials, meta-analysis, and systematic reviews showed the effectiveness of primary practice complex, multifaceted interventions, and organizational improvements facilitating structured and regular review of patients, patient education, and support by nurses, dietitians, and diabetes educators to reduce risk factors, improve the process of care, and decrease specialist referrals. Studies also showed similar clinical outcomes of people with type 2 diabetes cared by general physicians, internists, or endocrinologists, while the cost of specialized care was significantly higher. Conversely, schemes with low support for family physicians and unstructured and disorganized primary care have worse glycemic control and higher mortality rates than hospital care. Chronic illness care is largely performed within the primary care setting, and the chronic care model has become a major rethinking and contributing factor for primary care. The chronic care model (CCM) delivers integrated management for noncommunicable diseases and has been successfully applied in diabetes. The CCM assumes that medical care is centered in the interaction of patients and practice teams, community support for self-management, and organization of healthcare inside and outside health systems. By comparison to usual care where isolated physicians give orders to patients, chronic disease management involves collaboration from a group of clinicians from diverse disciplines (nurse case managers, physicians, pharmacists, social workers, dietitians, lay health workers) who communicate regularly and deliver healthcare to a defined group of patients.