Intensive control produces positive results, a few harms
The Diabetes Control and Complications Trial (DCCT)6 showed that, in patients with type 1 diabetes, “intensive” diabetic control managed by a large team of health care providers for an average of 6.5 years reduced the development of retinopathy (number needed to treat [NNT]=6; 95% CI, 5-7), progression of retinopathy (NNT=5; 95% CI, 4-7), and development or progression of clinical neuropathy (NNT=13; 95% CI, 11-18).7 Intensive therapy also caused harms, including episodes of hypoglycemia (number needed to harm [NNH]=3), and “hypoglycemia requiring assistance” (NNH=36).
In the follow-up to DCCT—the Epidemiology of Diabetes Interventions and Complications study (EDIC)—93% of the patients in the original cohort were followed for an average of 17 years.8 The risk of developing any predetermined cardiovascular event was 42% less in the intervention group (NNT=14; 95% CI, 9-65), and the combined risk of death, nonfatal myocardial infarction, or stroke was 57% lower (NNT=10; 95% CI, 7-49). Harms, such as hypoglycemia, were not reported.
Recommendations
According to the American Diabetes Association, patients with diabetes should receive medical care from a physician-coordinated team, which may include nurse practitioners, physician’s assistants, nurses, dieticians, pharmacists, and mental health professionals.9
The Centers for Disease Control and Prevention strongly recommends that patients with diabetes be assigned “a case manager to plan, coordinate, and integrate care,” because case management improves glycemic control and physician monitoring.10
The American Association of Clinical Endocrinologists states: “Managing diabetes mellitus requires a team approach to patient care. However, because diabetes is primarily a self-managed disease, education in self-management skills is essential in implementing interventions.”11