The JEVIN trial: A population-based survey on the quality of diabetes care in Germany: 1994/1995 compared to 1989/1990

Abstract

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].

Hyperglycaemic crises and lactic acidosis in diabetes mellitus

“…The annual incidence of DKA among subjects with type 1 diabetes is between 1% and 5% in European and American series [6][7][8][9][10] and this incidence appears to have remained relatively constant over the last decade in Western countries. Episodes of DKA are more common in younger than older subjects and are twice as common in females than males.…”

Influence of Health Care Providers on the Development of Diabetes Complications

“…Little prospective research is available that examines the influence of diabetes specialist care on complication outcomes. In a study by Schiel et al (24), decentralization of diabetes care from specialist centers to general practice demonstrated an increase in rates of proliferative retinopathy and worse glycemic control in people with type 1 diabetes when comparing nonspecialized care in the decentralized system to centralized diabetes care. This study, however, did not follow the same cohort for the two time periods.…”

“…Other studies examining effects of specialist care have not used standardized methods to classify care, as was done in this study. Additionally, studies examining this research question have been cross-sectional in nature (3,4,24,28,30) or conducted in clinic populations (5,9,10,31) with few examining complication outcomes. Studies examining the interrelationship between types of care received, socioeconomic factors, and complication outcomes appear to be absent in the literature.…”

Targets and reality: a comparison of health care indicators in the U.S. (Pittsburgh Epidemiology of Diabetes Complications Study) and Hungary (DiabCare Hungary).

“…Jena's St. Vincent Trial (JEVIN) Study from the former German Democratic Republic (East Germany) reported a significant worsening of glycemic control among type 1 diabetic patients after the decentralization of the health care system (5). In other European countries, intensive insulin therapy was successfully implemented in primary care after extensive inpatient education (6)(7)(8), and in the U.S., several initiatives with local quality-control procedures have shown significant beneficial effects on diabetes care (3,9).…”