SummarySince 1990 in most Eastern European countries health care systems have been decentralized or are undergoing the processes of decentralization. Increasingly, diabetic patients are no longer treated by diabetologists but by non-specialized physicians. During the same period structured treatment and teaching programmes have been introduced and health care is increasingly influenced by the St. Vincent declaration. To show the effect of these changes on the quality of diabetes care 90 % (n = 244) of all insulin-treated diabetic patients aged 16 to 60 years and living in the city of Jena (100247 inhabitants) were studied in 1994/1995. The results were compared with the baseline examination of 1989/1990 (n = 190). HbAac (HbAlc/mean normal) in IDDM patients under specialized care was similar in 1994/1995 (1.54+0.27, n=47) to 1989/1990 (1.52+0.31, n = 131, p = 0.0018), but higher under non-specialized care (1.71 + 0.38, n = 80,p = 0.0087). In the total group of NIDDM patients there was no significant change in HbAlc (1994HbAlc ( /1995HbAlc ( :1.75 + 0.4, n = 117, vs 1989HbAlc ( /1990:1.78 + 0.4, n = 59,p = 0.67), but with a tendency to higher HbAlc under non-specialized (1.81+0.4, n =79) compared to specialized care (1.66 + 0.39, n = 38, p = 0.06). Incidence of severe hypoglycaemia (IDDM 0.13; NIDDM 0.04), ketoacidosis (0.02; 0.01) and the prevalence of nephropathy (21%; 35 %) and neurogathy (24 %; 38 %) remained unchanged in comparison to 1989/1990, whereas there was an increase in the prevalence of diabetic retinopathy. Specialized care is mandatory for patients with IDDM. [Diabetologia (1997[Diabetologia ( ) 40: 1350[Diabetologia ( -1357 Keywords IDDM, NIDDM, population-based trial, HbAlc, care quality.Insulin-dependent (IDDM) and non-insulin-dependent (NIDDM) diabetes mellitus confer a high risk of developing diabetic late complications with the result of excess mortality and morbidity [1][2][3][4][5]. Up to the present, optimal quality of care and regular screening have been the most important factors for preventing late complications [6][7][8][9][10]. Most of the data available concerning quality management of diabetes have been derived from selected populations [11,12].

The benefits of insulin pump therapy are improvement of HbA1c, reduction of hypoglycaemia, ketoacidosis and hospitalisation days as well as improved flexibility. It is possible to draw up a list of clinical criteria and service requirements, which are likely to reduce failures.

OBJECTIVE -Diabetes treatment and teaching programs (DTTPs) for type 1 diabetes, which teach flexible intensive insulin therapy to enable dietary freedom, have proven to be safe and effective in routine care. This study evaluates DTTP outcomes in patients at high risk for severe hypoglycemia and severe ketoacidosis.RESEARCH DESIGN AND METHODS -There were 96 diabetes centers that participated between 1992 and 2004. A total of 9,583 routine-care patients with type 1 diabetes were examined before and 1 year after a DTTP. History of repeated severe hypoglycemia/severe ketoacidosis was an indication for DTTP participation. Before-after analyses were performed for subgroups of patients with three or more episodes of severe hypoglycemia or two or more episodes of severe ketoacidosis during the year before a DTTP. Main outcome measures were GHb, severe hypoglycemia, severe ketoacidosis, and hospitalization.RESULTS -A total of 341 participants had three or more episodes of severe hypoglycemia the year before a DTTP. Mean baseline GHb was 7.4 vs. 7.2% after the DTTP, incidence of severe hypoglycemia was 6.1 vs. 1.4 events ⅐ patient Ϫ1 ⅐ year Ϫ1 , and hospitalization was 8.6 vs. 3.9 days ⅐ patient Ϫ1 ⅐ year Ϫ1 . In mixed-effects models taking effects of centers and diabetes duration into account, mean difference was Ϫ0.3% (95% CI Ϫ0.5 to Ϫ0.1%; P ϭ 0.0006) for GHb and Ϫ4.7 events ⅐ patient Ϫ1 ⅐ year Ϫ1 (Ϫ5.4 to Ϫ4; P Ͻ 0.0001) for severe hypoglycemia. A total of 95 patients had two or more episodes of severe ketoacidosis. GHb was 9.4% at baseline versus 8.7% after DTTP; incidence of severe ketoacidosis was 3.3 vs. 0.6 events ⅐ patient Ϫ1 ⅐ year Ϫ1 , and hospitalization was 19.4 vs. 10.2 days ⅐ patient Ϫ1 ⅐ year Ϫ1 . In linear models with diabetes duration as the fixed effect, the adjusted mean difference was Ϫ2.7 events ⅐ patient Ϫ1 ⅐ year Ϫ1(95% CI Ϫ3.3 to Ϫ2.1; P Ͻ 0.0001) for severe ketoacidosis and Ϫ8.1 days (Ϫ12.9 to Ϫ3.2; P ϭ 0.0014) for hospitalization.CONCLUSIONS -Patients at high risk for severe hypoglycemia or severe ketoacidosis may benefit from participation in a standard DTTP for intensive insulin therapy and dietary freedom.

Adolescents and young adults with Type 1 diabetes benefit from participation in a standard DTTP for flexible, intensive insulin therapy and dietary freedom.

In an average of 5.8 years after the diagnosis of GDM, the majority of women still have chronic insulin resistance. One third has either IGT, IFG or diabetes mellitus. Therefore, a long term follow-up is strongly recommended for women diagnosed with GDM.