These pages are best viewed with Netscape version 3.0 or higher or Internet Explorer version 3.0 or higher. When viewed with other browsers, some characters or attributes may not be rendered correctly.ORIGINAL ARTICLE Intensified Treatment and Education of Type 1 Diabetes As Clinical Routine A nationwide quality-circle experience in Germany Ulrich A. Müller, MD, MSC, PHD This contribution describes the nationwide implementation of an intensive treatment and education program for type 1 diabetic patients in the clinical routine of the German health care system. Based on the formation of a working group (Arbeitsgemeinschaft Strukturierte Diabetestherapie [ASD]) of presently 57 general internal medicine departments, mainly from secondary and tertiary care levels in city and country hospitals throughout the country, a peer-review quality circle was formed as an official working group of the German Diabetes Association. The participating institutions performed a structured program of intensive treatment and education in all type 1 diabetic patients referred to them on a routine basis. The program includes multiple daily insulin injections or continuous subcutaneous insulin infusion, several times daily blood glucose self-monitoring and self-adaptation of insulin dosages and other aspects of treatment by the patients, and a far-reaching liberalization of the nutrition regimen. The group has attempted to document and to improve the quality of the structure and process of type 1 diabetes care in its participating institutions by a system of peer supervision. Furthermore, all member institutions volunteered to collect outcome data based on systematic 1–1.3 years' follow-up examinations of consecutive type 1 diabetic patients. For the 1997 evaluation of 1,103 type 1 diabetic patients, significant decreases of GHb levels and of incidence rates of severe hypoglycemia (from 0.35 to 0.16 cases per patient-year) and ketoacidosis (from 0.08 to 0.02 cases per patient-year) are presented. The ASD quality circle represents a model to improve principal aspects of type 1 diabetes care on a nationwide basis. Diabetes Care 22 (Suppl. 2):B29–B34, 1999 Principal objectives for the treatment of type 1 diabetes include near-normalization of glycemic control to prevent incidence and progression of diabetic microangiopathy, avoidance of acute complications—namely, severe hypoglycemia—and a quality of life that is the least possibly hindered by the disease and/or its therapy (1). With the (re)introduction of intensified insulin therapy based on self-treatment by the specifically trained patient, it has become possible to approach these objectives in a more realistic fashion. Yet, in most health care systems, intensified treatment for type 1 diabetes is still regarded as experimental, is recommended only to a minority of patients by a minority of physicians, and is felt to be unsuitable for routine use, i.e., outside of institutions specializing in diabetes care. In this report, we describe the implementation of intensified treatment of type 1 diabetes as a clinical routine in 57 hospitals in Germany and its outcome evaluation in >4,500 unselected patients. Intensified treatment (IT) of type 1 diabetes was originally defined as a systematic therapeutic plan consisting of intensified insulin substitution (multiple daily insulin injections, including twice-daily NPH insulin, or continuous subcutaneous insulin infusion) dose-adapted by the patients based on blood glucose self-monitoring several times a day and a liberalization of dietary regulations (avoidance of meal planning) and other lifestyle restrictions based on a comprehensive structured group treatment and teaching program with the aim to train and to encourage the patients to conduct self-therapy (Geneva-Düsseldorf program). IT was initiated during a hospitalization of 5 days. IT's efficacy (reductions of HbA1c levels) and safety (unchanged or even reduced incidence of severe hypoglycemia; almost complete eradication of diabetic ketoacidosis), in parallel with an advanced liberalization of the patients' nutritional habits, have been proven in several prospective uncontrolled studies as well as in a randomized controlled trial for up to 6 years (2–4). In fact, the IT program has been used with comparable success by diabetes centers in a number of countries in Europe and beyond (5–8). In 1993, it was shown that the translation of the IT program from the specialized diabetes center at Düsseldorf University to nine general internal medicine departments in city and country hospitals in Germany was possible without any loss of effectiveness or safety (9), and the conditions for such a successful translation of the program were described (9). Subsequently, a group of general internal medicine departments in city and country hospitals and in university departments decided to form a working group of the German Diabetes Association (Arbeitsgemeinschaft Strukturierte Diabetes Therapie [ASD], or the Working Group on Structured Diabetes Therapy) aimed at implementing IT for type 1 diabetic patients in their routine practice of diabetes care. To be able to monitor the efficacy and safety of IT under these circumstances, the group developed into a quality circle, with systematic monitoring of structure, process, and outcome quality of type 1 diabetes treatment in all participating institutions. This report describes the efforts and results of the ASD during the past 5 years as the first documentation of a nationwide implementation of IT of type 1 diabetes; it demonstrates the substantial improvement in diabetes care outcome variables in some 4,000 type 1 diabetic patients. RESEARCH DESIGN AND METHODS— In 1991, the German Diabetes Association issued guidelines for the quality assurance of centers providing treatment and teaching programs for type 1 diabetic patients (10). The criteria for a center designation included several aspects of structure and process quality based on self-reporting by the institutions. To make a more specific effort to improve the quality of type 1 diabetes care, in 1992, a group of senior physicians from some 30 general internal medicine departments from all over Germany founded an official working group of the German Diabetes Association (the ASD). Over the past years, this group has developed into a quality circle of currently 57 institutions with the objective of improving all quality aspects of type 1 diabetes treatment. Presently, some 70 institutions are registered with the ASD, but so far only 57 have fulfilled the various constitutional requirements for full membership. This report is based on the data of these 57 institutions (listed in acknowledgments). Basic requirements for acceptance into the ASD for a department of internal medicine included 1) having a particular inpatient division of diabetes with a physician diabetologist, a diabetes educator (certified by the German Diabetes Association based on a comprehensive 3-month postgraduate training course), and a dietitian, and 2) offering a structured treatment and group teaching program for intensification of therapy based on a written curriculum covering some 20 h. For each type 1 diabetic patient, a defined set of data (concerning clinical characteristics, medical history including detailed information concerning acute complications during the past 12 months, etc.) had to be documented at entry. In accordance with the present German health care system, most of the member institutions did not have the possibility to follow-up on their patients in an outpatient clinic; rather, after the initiation of IT in the context of a hospitalization usually of 5 days, patients were primarily followed by the family physicians who had referred them to the hospitals in the first place. Over and above the guideline criteria proposed by the German Diabetes Association for "type 1 diabetes treatment centers," ASD decided from the time of its foundation to establish the following elements of quality control on a mandatory basis for all its participating institutions. First, to assure adequate levels of structure and process quality, a system of reciprocal hospital visitations (peer supervision system) was implemented whereby physician and educator members of the diabetes care team from one institution visit another ASD member center to follow the entire length of the structured inpatient treatment and teaching program (usually of 5 days' duration). The group agreed on a specific structure for this kind of supervision: a checklist covering 37 items concerned with the structure of the institution, the type of team interactions between its members, and the pedagogic level of the teaching processes is to be completed by the supervisors. At the end of the supervision visit, a formal discussion is held between visitors and team members. The checklist results are made public in the reports of the ASD and are discussed in detail during its annual meeting—with no attempt to make the data anonymous. Each member institution of the ASD is to be subjected to the supervision process at least biannually. The process is being organized by the ASD's administrative center (presently located at the Department of Medicine II, Friedrich-Schiller-University Jena). Second, from the beginning of its existence, the ASD was determined to document the outcome quality of their member institutions' type 1 diabetes treatment programs. To this end, patients would have to be followed up prospectively in a systematic fashion over some time. Even though most of the member institutions did not have the opportunity to see patients in an outpatient clinic and thus follow-up examinations would create personnel and financial problems, the ASD decided that the systematic performance of an outcome analysis procedure should be mandatory for its participating members. Every 2–3 years, each institution is to perform follow-up studies on a group of at least 50 consecutive type 1 diabetic patients 12–15 months after they were hospitalized for IT. Diabetes secondary to pancreatectomy and patients with a history of frequent hypoglycemia were included; patients with diabetes of <3 months' duration and women with gestational diabetes were excluded, as were patients with blindness and serum-creatinine levels of >2.0 mg/dl. The ambulatory follow-up investigation for which the patients were invited to the hospital unit had only four mandatory variables: GHb, incidence rates for severe hypoglycemia, incidence rates for diabetic ketoacidosis, and days of hospitalizations during the follow-up period. Additional information was collected on an optional basis. For the outcome analysis to be accepted as valid, at least 90% of the initial cohort of patients had to be reexamined. The results of these outcome analyses are being published in the reports of the ASD and openly discussed at its annual meeting with regard to possible reasons for differences between participating institutions. The data collection, plausibility checks, etc., are being performed by the ASD's administrative center. As far as the documentation of GHb levels is concerned, the ASD did have the problem that different assay methods were being used throughout the country, thus making the raw data reported by the institutions hardly comparable. Until a uniform method to assay HbA1c is introduced (probably within the next few months), the group has decided to correct the reported levels for HbA1c by the mean of the respective assay's normal range (which had to be established for each institution separately) and present them as
As long as uniform methods for determination of GHb remain unavailable throughout the country, this transformation should be useful to approximately compare the levels of glycosylated hemoglobin in type 1 diabetic patients as achieved by the ASD institutions' IT with the results of other studies and audits directed at normalizing glycemic control. The other three items of the mandatory outcome evaluation were assessed based on a structured interview with the patient to assess the incidence rates of severe hypoglycemia, ketoacidosis, and hospitalization days before the initiation of IT and at the follow-up examination retrospectively for the preceding year. Severe hypoglycemia was defined as a self-reported episode of hypoglycemia necessitating treatment with intravenous glucose or glucagon injection, in accordance with the definition used during the feasibility study of the Diabetes Control and Complications Trial (11). Diabetic ketoacidosis was defined as a metabolic decompensation with biochemical and clinical signs of ketoacidosis and hyperglycemia treated in an emergency room or in a hospital. Hospitalizations for whatever reason were assessed while interviewing the patients; in a previous study, the reliability of this method of data collection was validated by a comparison with the complete information set maintained at the health insurance companies (13). Presently, the ASD is in the process of preparing a computerized recall and evaluation system (DIQUAL; supported by Hoechst-Marion-Roussel) to facilitate all outcome evaluations for its member institutions. Conventional statistical methods were applied, using Student's t
test or the
RESULTS— In the framework of this report, mainly results from the 1996 and 1997 evaluations of the ASD are included, although the group does perform continuous quality assurance and has completed respective outcome evaluations in some 4,800 type 1 diabetic patients since 1992. As of 1997, 57 participating institutions had been admitted as full members to the group, based on the presentation of the entire set of conditions as described above. Of these institutions, five were represented by University Medical School divisions, and the remaining were based in general internal medicine departments of city and country hospitals of secondary or tertiary care standards. The geographic distribution of the centers is somewhat heterogenous (Fig. 1), which is in part due to the differences in population density. In any case, to date a particularly successful recruitment of hospitals into the ASD appears to have taken place in the federal state of North-Rhine-Westfalia. Between 1993 and 1997, 114 supervision visits were conducted by peers, duly reported to the ASD administrative office, and discussed in detail during the group's annual meeting. This procedure has successfully contributed to the objective of standardizing the program for IT in the member institutions in accordance with the prototype Düsseldorf-Geneva treatment and teaching program, for which adequate scientific evidence concerning efficacy and safety had been documented. However, with regard to certain formal elements of the program, such as the prolongation of the hospitalization phase by up to 5 days, participating institutions were not restricted. In addition, the peer reviews have led to intensive discussions concerning the qualities of team interactions, pedagogic standards, and the overall atmosphere during the supervision process. The emphasis of this type of standardized supervision is on open and intense discussion between peers with the aim of improving various elements of the IT equally in the institutions that are being supervised and those that are supervising. Much of these discussions are brought up during the plenary meetings of the ASD, usually held in March of each year. As a result of this peer supervision procedure, the following changes in pedagogic and team interaction have been documented.
As an example of a change in the quality of hospital processes, it was achieved that every patient received the final written report for the family physician and a copy for the patient him- or herself on the very day of discharge from the hospital.
With regard to the outcome analyses, most participating institutions had no experience with this type of data collection; hence, during the first years, the process of data collection had to be optimized in accordance with the above-mentioned basic requirements laid out by the ASD. In fact, by 1997, the completeness with which the basic requirements for the evaluation process of the group were met by the participating centers was quite remarkable (Table 1). This objective was achieved by using elements of the quality-circle approach.
During the year 1996–1997, 23 ASD institutions reexamined a total of 1,103 type 1 diabetic patients 12–15 months after their hospitalization to initiate IT. The overall results can be seen in Table 2. In 21 institutions, a decrease of glycosylated hemoglobin was noted. In 20 institutions, a decrease of the incidence of severe hypoglycemia was documented. In 11 centers, no cases of diabetic ketoacidosis were recorded during the follow-up period. In addition, in all but one institution, a reduction of hospitalization days was documented. With the significant fall in hospitalizations by a mean of 3 days per patient per year, the IT intervention becomes cost-effective under the conditions of the German health care system, in accordance with previously detailed cost-effectiveness analyses (4,14). These results confirm the earlier results from those patient evaluations that fulfilled all criteria of completeness during the years 1992–1996 (15), when the relative HbA1c fell from 1.67 to 1.42 in 1,609 patients and the incidence of severe hypoglycemia decreased from 0.32 to 0.18 cases per patient per year in 966 patients.
On a more detailed analysis of the 813 patients of the 1996–1997 evaluation for whom anonymous original data were made available to the ASD administrative center using the computerized DIQUAL data collection system, a breakdown according to individual treatment objectives was performed in a post-hoc analysis. Thus, patients were divided into those with an initial relative HbA1c of >1.6 (approximately corresponding to an high performance liquid chromatography HbA1c of >8.0%), in whom improvement of glycemic control was a primary therapeutic goal; and those with an initial relative HbA1c of <1.6%, in many of whom the reduction of severe hypoglycemia was the main treatment goal (Table 3). The specific benefit to the patients with respect to their individual problems of diabetes care was clearly demonstrated, i.e., more apparent than on presentation of mean values for the entire cohort (Table 2) only. CONCLUSIONS— This report documents for the first time that IT can be successfully implemented into a country's general health care system as the routine care for type 1 diabetic patients. Based on the scientific proof of efficacy and safety of the IT program (1,2,11,16) and a formal study describing the conditions for the translation of the IT program to nonspecialized hospital units (9), a group of some 57 general internal medicine departments (including <10% divisions of university hospitals) have agreed to treat all type 1 diabetic patients referred to them for improvement of diabetes care with IT. These institutions have volunteered to subject themselves to peer supervision concerning the structure and process quality of their diabetes program and to perform systematic outcome quality analyses. Furthermore, the institutions have mutually agreed to make the data of all these analyses public and discuss them openly without any institutional anonymity. In defining these regulations and activities as their basis and their objectives, the group fulfilled the requirements of a quality circle (17); furthermore, it drew up its own constitution and was officially registered as a working group of the German Diabetes Association. Over the past 5 years of its existence, the ASD has grown in number of member institutions. This reflects a most rewarding interest of diabetologists and general internal medical departments in systematically improving the standards of type 1 diabetes care; the development is all the more encouraging because no financial incentives are connected with the particular efforts to implement and evaluate IT by the various hospital departments. Because the outcome data documented for these hospital units are very satisfactory, however, it has been suggested that health insurance companies and other types of third-party payers should restrict the financial support for elective hospitalizations of type 1 diabetic patients to those centers that participate in the ASD activities of quality assurance. These results as provided by the ASD demonstrate the possibility of substantially improving HbA1c levels—along with decreasing the incidence of severe hypoglycemia, almost completely eradicating diabetic ketoacidosis, and reducing the hospitalization days for type 1 diabetic patients—by implementing IT on a routine basis in a very large number of patients. In addition (but not shown in this report), IT provides for a far-reaching liberalization of the diet and other lifestyle measures (18) and, hence, an improvement of preference-weighted quality-of-life measures (19). In fact, outcome analyses provided by the ASD over the past years, with increasing completeness and validity, do compare favorably with respective data from highly financed classic intervention trials (20,21). Limitations in interpretation of outcomes studies in type 1 diabetes have been discussed previously (11). The basis for this improvement of type 1 diabetes care (even without an intervention at the level of primary care physicians) was the adoption of an effective and safe structured treatment and teaching program (the Düsseldorf-Geneva IT) and the ongoing systematic efforts for quality assurance and improvement concerning the structure, process, and outcome of the IT program. This novel approach, implementing the methodological principles of the quality circle, and the positive outcome of primary parameters of type 1 diabetes care and its cost-effectiveness appear to make the ASD a model for systematic improvements of health care in diabetes and other chronic diseases in any given health care system. For this model to substantially improve type 1 diabetes care standards in Germany, an ASD-associated diabetes center would have to be established for every 300,000–400,000 inhabitants. It is estimated that ~200 ASD diabetes centers would be necessary for the whole region of Germany. Considering that the number of active ASD members has continuously increased over the years, it seems likely that the necessary number of centers will be established in the near future. (As of March 1998, 135 hospitals, including 10 university hospitals, had already applied for membership.) Given the concentration of diabetes care institutions as active participants of the ASD in the state of North-Rhine-Westfalia, it is not surprising to see comparably positive standards of structure, process, and outcome quality measures in a large representative cohort of type 1 diabetic patients of the region of North-Rhine comprising 9.5 million inhabitants altogether (6,22). Financial incentives should now be used to facilitate the intensification of efforts directed at improving type 1 diabetes care by the ASD and to enlarge the membership of the group to achieve a nationwide advancement of the routine care offered to every diabetic patient in this country. Acknowledgments— Hoechst-Marion-Roussel has been instrumental in organizing and financially supporting the annual meetings of the ASD, in establishing an ASD administrative office with a part-time administrator, and in the ongoing development of the DIQUAL data collection system. These efforts by Dr. Dieter Leihener and his collaborators from Hoechst-Marion-Roussel are greatly appreciated. M.B. was supported by the P. Klöckner Stiftung, Duisburg, Germany. At the ASD's 1997 annual spring meeting, the following colleagues and institutions were actively contributing members of the group. Their impact into this first report of the ASD's efforts is gratefully acknowledged: Dr. C. Deparade (Marienhospital Aachen); Dr. R. Schwarz (Augsburg-Haunstetten); Dr. M. Jecht (Gemeinschaftskrankenhaus Havelhöhe, Berlin); Dr. H. Echterhoff (Krankenanstalten Gilead, Bielefeld); Dr. M. Ristow (Klinikum Bergmannsheil, Bochum); Dr. Heer (Zentralkrankenhaus Bremen-Nord); Dr. B. Schneider-Schultes (St. Joseph-Stift, Celle); Dr. J. Teller (Krankenhaus Flemmingstraße, Chemnitz); Dr. Nilles (St. Vinzenz Hospital, Dinslaken); Dr. Demtröder (Städt. Kliniken Dortmund-Mitte, Dortmund); Dr. A. Risse (Städt. Kliniken Dortmund-Nord, Dortmund); Dr. J. Kersken (St. Johannes Hospital, Oberhausen); Dr. S. Bott (University Hospital, Düsseldorf); Dr. M. Femerling (County Hospital Eckernförde); Dr. U. Schauer (Klinikum Erfurt); Dr. Förster (Bethesda-Krankenhaus, Essen); Dr. B. Schulze-Schleppinghoff (St. Elisbeth Krankenhaus, Essen); Dr. Münch (Malteser Krankenhaus, Flensburg); Dr. D. Teßmann (Städt. Kliniken Hoechst, Frankfurt/M); S. Endrulat (Krankenhaus Sachsenhausen, Frankfurt/M); Dr. E. Reber (University Hospital Frankfurt/M); Dr. Clemens-Harmening (Bethesda Krankenhaus, Freudenberg); Dr. I. Röhrig (Diabetes Zentrum Rheinland, Haan); Dr. M. Reuter (Allgemeines Krankenhaus, Hagen); Dr. G. Bangert (Allgemeines Krankenhaus Barmbeck, Hamburg); Prof. M. Dreyer (Krankenhaus Bethanien, Hamburg); Dr. P. Zimmer (Klinikum Ingolstadt); Dr. U.A. Müller (University Hospital, Jena); Dr. Rjasanowski (G. Katsch Klinikum Karlsburg); Dr. Spuck (Rotes-Kreuz-Krankenhaus, Kassel); Dr. Schnepper (Städt. Krankenhaus Kemperhof, Koblenz); Prof. Mies (St. Antonius Krankenhaus, Köln); Dr. G. Willms (Städt. Krankenhaus, Köln-Porz); Dr. B. Beuscher (Evangel. Krankenhaus, Kreuztal-Kredenbach); Dr. Zimmermann (Frankenwaldklinik, Kronberg); Dr. J. Steindorf (Städt. Klinik Leipzig-West, Leipzig); Dr. Richter (St. Bonifatius Hospital, Lingen); K. Kraatz (Städt. Klinikum, Ludwigshafen); Dr. E. Küstner (University Hospital, Mainz); Dr. R. Renner (Städt. Krankenhaus Bogenhausen, München); Prof. Standl (Städt Krankenhaus Schwabing, München); Dr. W. Piehlmeier (University Hospital, München); Prof. W. Wiegelmann (HerzJesu Krankenhaus, Münster); Dr. Böckmann (Friedrich-Ebert Krankenhaus, Neumünster); Dr. B. Beier (Krankenhaus St. Raphael, Ostercappeln); Dr. A. Zaruchas (St. Johannsesstift, Paderborn); Dr. M. Rohe (Christl. Krankenhaus, Quakenbrück); Dr. H. Nusser (University Hospital, Regensburg); Dr. M. Voss (Mathias Hospital, Rheine); Dr. M. Reckels (Diakonie- Krankenhaus, Rotenburg/Wümme); Dr. M. 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Starostina E, Antsiferov M, Galstyan GR, Trautner C, Jörgens V, Bott U, Mühlhauser I, Berger M, Dedov I: Effectiveness and cost-benefit analysis of intensive treatment and teaching programmes for type 1 (insulin-dependent) diabetes mellitus in Moscow. Diabetologia 37:170–176, 1994 5. Berger M, Mühlhauser I: Implementation of intensified insulin therapy: a European perspective. Diabet Med 12:201–208, 1995 6. Mühlhauser I, Overmann H, Bott U, Jörgens V, Berger M: Erfassung der Versorgungsqualität von erwachsenen Personen mit Typ-I-Diabetes im Ärztekammerbereich Nordrhein. In Die Forderungen von St. Vinzent: Stand 1996 in Deutschland. Berger M, Trautner C, Eds. Mainz, Germany, Kirchheim Verlag, 1996, p. 97–104 7. Assad D, Puchulu R, Domenech MI, Mercuri N, Coppola L, Mazzei ME, Kronsbein P, Gagliardino JJ: Evaluación de un programa ambulatorio de educación y tratamiento de pacientes diabéticos insulinodependientes. Revista Asociación Latinoamericana de Diabetes 3:19–22, 1995 8. Pieber TR, Brunner GA, Schnedl WJ, Schattenberg S, Kaufmann P, Krejs GJ: Evaluation of a structured outpatient group education programme for intensive insulin therapy. Diabetes Care 18:625–630, 1995 9. Jörgens V, Grüsser M, Bott U, Mühlhauser I, Berger M: Effective and safe translation of intensified insulin therapy to general internal medicine departments. Diabetologia 36:99–105, 1993 10. Deutsche Diabetes Gesellschaft: Qualitäts-richtlinien und Qualitätskontrolle von Therapie- und Schulungseinrichtungen für Typ I Diabetiker. Diabetologie-Informationen 13:185–186, 1991 11. Bott S, Bott U, Berger M, Mühlhauser I: Intensified insulin therapy and the risks of severe hypoglycaemia. Diabetologia 40:926– 932, 1997 12. The DCCT Research Group: Diabetes Control and Complications Trial (DCCT): results of feasibility study. Diabetes Care 10:1–19, 1987 13. Mühlhauser I, Klemm AB, Boor B, Scholz V, Berger M: Krankenhausaufenthalte und Arbeitsunfähigkeitszeiten bei Patienten mit Typ I Diabetes mellitus. Dtsch Med Wschr 111:854–857, 1986 14. Trautner C: Cost-benefit analyses of patient education. In Diabetes1994. Baba S, Kaneko T, Eds. Amsterdam, Elsevier, 1995, p. 990–996 15. Müller UA, Reinauer KM, Voss M, Köhler S: Programme zur Verbesserung der Stoffwechseleinstellung (Sekundärprävention) bei Typ-I-Diabetes. In Die Forderungen von St. Vinzent: Stand 1996 in Deutschland. Berger M, Trautner C, Eds. Mainz, Germany, Kirchheim Verlag, 1996, p. 97–104 16. Berger M, Jörgens V: Praxis der Insulintherapie. 5th ed. Berlin, Springer, 1995 17. Hartmann P, Bott U, Grüßer M, Jörgens V: Effect of peer-review groups on physicians' practice. Eur J Gen Pract 1:107–112, 1995 18. Mühlhauser I, Bott U, Overmann H, Wagener W, Bender R, Jörgens V, Berger M: Liberalized diet in patients with type 1 diabetes. J Intern Med 237:591–597, 1995 19. Bott U, Mühlhauser I, Overmann H, Berger M: Validation of a diabetes-specific quality of life scale for patients with type 1 diabetes. Diabetes Care 21:757–769, 1998 20. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977–986, 1993 21. Reichard P, Bengt-Yngve N, Rosenqvist U: The effect of long-term intensified insulin treatment on the development of microvascular complications of diabetes mellitus. N Engl J Med 329:304–309, 1993 22. Mühlhauser I, Overmann H, Bender R, Bott U, Jörgens V, Trautner C, Siegrist J, Berger M: Social status and the quality of care for adult people with type 1 diabetes: a population based study. Diabetologia 41:1139–1150, 1998 From the Department of Medicine II (U.A.M.), Friedrich-Schiller University Jena, Jena; the Department of Medicine (M.F.), Division of Diabetes, County Hospital Eckernförde, Eckernförde; the Department of Medicine and Geriatrics (K.M.R.), Municipal Hospital Sindelfingen, Sindelfingen; the Department of Medicine (A.R.), Municipal Hospital Dortmund North, Dortmund; the Department of Diabetes (M.V.), County Hospital, Mathias-Spital Rheine, Rheine; the Department of Metabolic Diseases and Nutrition (WHO Collaborating Center for Diabetes) (V.J., M.B.), Heinrich-Heine University Düsseldorf, Düsseldorf; and Health Sciences and Education (I.M.), University Hamburg, Hamburg, Germany. Address correspondence and reprint requests to Dr. Ingrid Mühlhauser, Klinik für Stoffwechselkrankheiten und Ernährung (WHO Collaborating Center for Diabetes), Moorenstr. 5, D-40225 Düsseldorf, Germany. Received for publication 27 May 1998 and accepted in revised form 18 September 1998. Abbreviations: ASD, Arbeitsgemeinschaft Strukturierte Diabetes Therapie (Working Group on Structured Diabetes Therapy); IT, intensified treatment. This article is based on a presentation at a satellite symposium of the 16th International Diabetes Federation Congress. The symposium and the publication of this article were made possible by educational grants from Hoechst Marion Roussel AG. Copyright © 1999 American Diabetes Association For Technical Issues contact webmaster@diabetes.org |
2 test to validate differences between groups as
appropriate. Unless otherwise indicated, means ± SD are given; P values of
<0.05 were considered statistically significant.
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