Abstract
Staged Diabetes Management (SDM) is a disease state management programme, that was developed by the International Diabetes Center, Minneapolis, USA. Its primary aim is to achieve nearโnormal to normal blood glucose control in all patients with diabetes, using community involvement and simple, complete clinical pathways. SDM contains methods of diagnosis, an overview of therapy, practice guidelines, and specific detailed treatment protocols (decision paths) for type 1 and type 2 diabetes and gestational diabetes (GDM). Formal training in SDM was conducted for participating physicians and nurses, including an introduction to the philosophy and approach of SDM, provision of the materials and elucidation of the expected goals and results. After training and implementation, a series of trials were performed to determine the effectiveness of SDM in improving diabetes care in this region. The trial results evaluated the overall influence of SDM on such clinical parameters as HbA~1c~ and fasting blood glucose, to assess the appropriateness of treatment modalities and timing of therapeutic choices, eg minimal delay to choice of appropriate stage.
The introduction of the SDM programme led to significant reductions of HbA~1c~ and fasting and postprandial blood sugar, without hypoglycaemia, in a representative group of people with type 1 diabetes. In patients with type 2 diabetes, significant reductions of HbA~1c~, fasting and postprandial blood glucose without hypoglycaemia or weightโgain was achieved.
To our knowledge, this is one of the first times that these goals have been achieved in people with type 1 diabetes, without hypoglycaemia, and in type 2 diabetes, without weightโgain. Using SDM we achieved 100% screening of 500 women referred for evaluation of menopausal symptoms. Approximately 5% of periโ and postโmenopausal women were found to have frank diabetes (type 2) and an additional 8% had impaired glucose tolerance. Using the SDM programme, tight metabolic control in pregnant women with type 1 diabetes decreased the incidence of serious complications, eg urinary tract infections and preโeclampsia, particularly in the critical last few weeks before delivery. We found a decrease in the incidence of serious neonatal complications in the SDM group โ lower levels of: neonatal death (none seen in the SDM group); fetal congenital malformations; hypoglycaemia and respiratory distress syndrome. With respect to GDM, screening of pregnant women and proper treatment using SDM resulted in lower pregnancy and neonatal complication rates as well as fewer Caesarean sections.
The success of these early pilot studies has led to a training programme that aims to introduce SDM to up to 500 primary care providers per year throughout Poland. Once trained, a larger more definitive multiโcentre study of the effects of SDM will be needed to confirm the earlier findings.