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Prof. Dr. med. Hermann Brenner, MPH

Prof. Dr. med. Elke Raum, MPH

Heike Krämer, Dipl. Ges-Ök. MSc Epidemiologie

Deutsches Krebsforschungszentrum

Abteilung Klinische Epidemiologie und Alternsforschung

Im Neuenheimer Feld 581

69120 Heidelberg

Tel.: 06221/42 1301              

Fax: 06221/42 1302

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Diabetes mellitus: New paths for optimising general practitioner care (DIANA)


Type 2 diabetes mellitus (T2DM) is among the most frequent chronic diseases in the developed industrial countries. Many of the affected patients are primarily cared for by physicians in GP practices. A considerable proportion of patients with T2DM shows a metabolic status that is worthy of improvement.



The aim of this study is to examine whether a patient-oriented GP care which also incorporates the resources of the patient improves fundamental outcome parameters of a diabetes therapy, for example hospital referrals due to diabetes, mortality or incidence of diabetes-associated secondary diseases.



In the framework of a care-epidemiological longitudinal study, in patients with diabetes mellitus type 2, the GP care situation will be evaluated using the Chronic Care Model (module I), which, besides concrete care processes, also takes into account the active role of the patient and a "proactive" practice team in terms of the improvement of the care situation. In a randomised, controlled intervention study, the sustainable benefit of a structured care by means of supportive telephone counselling compared to "usual care" will be examined (module II). For module I, 1,146 diabetics were recruited in the first funding phase. The already established study collective of the intervention study for module II consists of a subgroup of 218 participants of the longitudinal study with initially unsatisfactory diabetes control (HbA1c > 7.5%). The patients randomised into the intervention arm received a telephone-based counselling from medical assistants of the GP for one year at monthly intervals.


In the framework of the project, a follow-up survey is now taking place after 3 years. The study results should demonstrate the status, changes and effects of a patient-oriented GP care in accordance with the Chronic Care Model as well as needs and possibilities for improvements in this regard. The focus lies on the sustainable influence of a patient-oriented procedure on the long-term target parameters of diabetes therapy, such as heart attack or stroke, functional impairments, hospital referrals, quality of life and mortality.



In the framework of the project, current data are gathered regarding the extent and trends of achievements made thus far in GP care in the implementation of key elements of the chronic care model. The quantification of the importance of this implementation for the course of illness of patients with diabetes mellitus can enable targeted measures for the improvement of care of these patients (module I).


The follow-up observation of the participants of the intervention study enables an evaluation of the sustainable use of a measure that can be well integrated into GP care for the mobilisation and strengthening of the patients' resources, the improvement of diabetic control and the reduction of the consequences of the disease (module II).


Link: Project homepage

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