Diabetes mellitus type 2: structured care and education
International Journal of Integrated Care, 1 March 2001 - ISSN 1568-4156
Book review
Diabetes mellitus type 2: structured care and education
Irma van den Arend, Thesis
Utrecht University, 2000, pp 149,
ISBN 90 901 4380 7
Rhys Williams

The world needs good books on this subject. Type 2 diabetes, the sort that used to be called ‘maturity onset diabetes’ or ‘adult onset diabetes’, cannot be known by that name any longer. It no longer only affects ‘mature’ and ‘adult’ people, it also affects young adults, teenagers and children as young as 8 or 9. Most of this change in age at onset is being seen in people such as those living in South Asia (India, Pakistan, Bangladesh and Sri Lanka) or of South Asian origin living in European countries. However, with the increase in childhood obesity being seen in many countries, this phenomenon is spreading fast. The phenomenon is caused, at least in part, by a lack of physical activity—through computer games and TV—and an increase in the energy density of our diet. The management of type 2 diabetes involves behavioural change and behavioural change is best achieved through structured care and education. This book tackles these issues head on.

When is a book not a book? When it is a thesis, as here. In the Netherlands, Denmark and a number of other countries the practice has been adopted of publishing, in book form, the work carried out as a thesis. What a good idea this is. Our own practice, in the United Kingdom, though it often results in the publication of articles, either during, or shortly after completion of higher degree work, often does not result in easy access to this sort of material. I often wonder how many theses are gathering dust on library shelves because of the in-built inertia of our system. The co-authors of journal papers based on the results of this particular thesis—Stolk, Krans, Grobbee, Schrijvers and others—are listed against six of the eight chapters.

These chapters cover a wide range of topics. After an introduction to the subject, the first substantive chapter is on the management of people with type 2 diabetes. This is described as ‘a challenge for patient and physician’. Subsequent chapters deal with the hospital costs of diabetes patients in the Netherlands; an education programme in the primary care setting; the impact of structured care on metabolic control; education integrated into structured care and, in the penultimate chapter, experts' opinions on the profile of optimal diabetes care in the Netherlands. There is a general discussion at the end. The volume is nicely presented with an adequate number of tables and figures and each of the chapters stands alone in terms of a useful and reasonably comprehensive list of references after each one.

A short summary of the aims of the work (the aims are given in full on page 6) is that it sought to evaluate structured care and education, in the primary health care setting, by assessing knowledge, ‘self-care behaviour’, disease perception and cardiovascular risk profile in people with diabetes. It also sought to ascertain, through expert opinion, the elements of primary care practice which contribute to optimal management. This last question is topical and important.

On reading the title of the first substantive chapter—‘Management of type 2 diabetes: a challenge for patient and physician’—the first question is ‘what about the rest of the team?’ The advent and effective functioning of the diabetes team—physician, nurse, dietician, podiatrist, and, in the best places, psychologist—have been, many would say, the best thing in the diabetes world since insulin became available. This chapter title is deceptive, however, because, earlier on in the work and intermittently throughout, the importance of the team is acknowledged and, what is more, the person with diabetes is, rightly, encouraged to be an active member of this team. However, it is rather disappointing that the roles of other professional members of the team are not more clearly acknowledged and that they were not studied as an integral part of the work.

The chapter on costs is rather short and deals only with hospital inpatient and nursing home costs. Admittedly, the first of these is the single largest contributor to direct health care costs but the chapter would have had considerably more substance had the scope of the economics work been wider. The information that is here is interesting, however. A ratio of 4 is described, between the costs of care for people with diabetes and the costs of care of people without diabetes. This is at the top end but still consistent with other work. Also noteworthy is the finding that the majority of this excess is not directly related to diabetes and its complications. The condition has an important indirect influence, through longer length of stay and greater intensity of treatment, even when the main cause of admission is not directly related to diabetes.

From Chapter 4 on, the volume really gets into its stride. The education programme is described, its impact on metabolic control evaluated (Chapter 5), and its influence on knowledge of diabetes and self-care described (Chapter 6). And the answer? Well, you will need to read the book to know that but the title of this last mentioned chapter does give just the gentlest of hints—‘Education integrated into structured care for type 2 diabetes results in sustained improvement of disease knowledge and self-care’.

The fact that Chapter 7 relies on expert opinion to identify the components of care that might result in best outcomes reveals that we are only just beginning to get to grips with the relationships between structure, process and outcome in diabetes health care research. The results of this enquiry placed ‘active patient participation’, ‘protocolized care’ and ‘patient education’ as the top three characteristics of care leading to best outcome. In the UK and other places we might term ‘protocolized care’ as ‘the use of clinical guidelines’ but, apart from that semantic change, I feel sure that most expert panels would agree with this assessment. What a joy it would have been if the panel members in this study had included other professionals or people living with diabetes. There is some reference here to the integration of care but the value of this chapter and, indeed, the whole volume, would have been enhanced if there could have been more focus on how this crucial integration might be achieved. This chapter, again, tends to be physician related rather than team related. However, it still provides results worth examining.

The final chapter lists and discusses some of the limitations of the studies and the implication of their results for diabetes care research and policy. This chapter ends with the statement ‘this may well be the time to act for all involved, to make use of their influence and promote the realization of optimal integrated diabetes care’. This is an apt exhortation, whether we are considering type 1 or type 2 diabetes. Let us hope that the days have gone when the latter was thought of as ‘mild diabetes’. Type 2 diabetes, particularly when it comes on early in life, is an important condition and has a potent impact as a result of cardiovascular disease and the specific complications of diabetes—impaired vision, renal failure, lower limb ulceration and gangrene. Interventions such as those described in this volume are essential if we are to deal with this important challenge.