Foot care practices of diabetic patients in Saudi Arabia

Diabetic foot is a serious complication that causes lower extremity amputations. The aim of this study was to identify the patient’s awareness about risk factors for diabetic foot disease and to explore the knowledge and foot care practices among diabetic patients in a Saudi population. This cross-sectional study was conducted in King Khalid University Hospital (KKUH), King Abdulaziz University Hospital (KAUH), King Fahad Medical City, National Guard Hospital, Military Hospital, and Prince Salman Hospital capital city of Saudi Arabia. Patients were eligible if they had diabetes foot disease, signed the consent form, and completed the questionnaire. We selected 350 patients from different hospitals between November-2011 and April-2012. The majority of patients (68%) were selected from King Saud University hospitals. The mean age of patients was 50.87 ± 15.9 years with a range of 20–90 years. The majority of patients were male (64.3%) and had a family history of hypertension (55.4%), high total cholesterol (58.6%), and other diabetes (58.9%). A family history of smoking, a major risk factor for diabetic foot, was found in 20.3% of cases. Sixty percent of the patients were using oral medications, 27.1% were using insulin therapy, 10% were using both oral and insulin therapies, and 10% were on diet. In our study, 19.4% of participants were illiterate while 80.6% had a high school or university level education. Our findings also revealed that some patients had a lack of knowledge concerning diabetic foot disease and future complications. Patients are unaware of the risk factors for diabetes foot and practice poor foot care. Awareness programs should be mandatory in all hospitals and diabetes clinics to help compensate for the lack of awareness and lack of podiatric educational services. Such programs may decrease the risk of diabetes foot disease.     

临床护理路径管理糖尿病足患者效果评价

目的:观察临床护理路径对糖尿病足患者的效果。方法:将100例糖尿病足患者随机分为两组:实验组(50例)应用临床护理路径模式,对照组采用常规护理模式,比较两组患者的住院时间、医疗费用、患者满意率、血糖、溃疡愈合时间和糖尿病足知识评分。结果:实验组患者的住院日数、医疗费用、血糖和溃疡愈合时间显著低于对照组(P<0.05),患者满意率和糖尿病足知识评分显著高于对照组(P<0.05)。结论:应用临床护理路径可以有效地降低糖尿病患者的血糖、溃疡愈合时间、住院时间和医疗费用,提高患者糖尿病足知识水平和满意率。     

A pilot study testing the feasibility of skin temperature monitoring to reduce recurrent foot ulcers in patients with diabetes – a randomized controlled trial

Background

Although monitoring foot skin temperatures has been associated with diabetic foot ulcer recurrence, no studies have been carried out to test the feasibility among European Caucasians. Moreover, the educational and/or motivational models that promote cognitive or psychosocial processes in these studies are lacking. Thus, we conducted a pilot randomized controlled trial to test the feasibility of monitoring foot skin temperatures in combination with theory-based counselling to standard foot care to reduce diabetic foot ulcer recurrence.

Methods

In a single-blinded nurse-led 1-year controlled trial, conducted at a hospital setting in Norway, 41 patients with diabetic neuropathy and previous foot ulcer were randomized to the intervention (n?=?21) or control groups (n?=?20). All participants were instructed in foot care and recording observations daily. Additionally, the intervention group was taught how to monitor and record skin temperature at baseline, and received counselling every third month supporting them to use the new treatment. Subjects observing temperature differences >2.0 °C between corresponding sites on the left and right foot on two consecutive days were asked to contact the study nurse and reduce physical activity. Fisher exact test was used to evaluate the effect of the intervention on the proportion of subjects with a foot ulcer. Kaplan-Meier survival analysis was performed to compare the two groups in regard to the time to development of a foot ulcer.

Results

In the intervention group, 67 % (n?=?14/21) monitored and recorded skin temperatures ≥80 % of the time while 70 % (n?=?14/20) of the controls recorded foot inspections. Foot ulcer incidence was 39 % (7/21) vs. 50 % (10/20) in the intervention and control groups, respectively (ns).

Conclusions

This feasibility study showed that the addition of counselling to promote self-monitoring of skin temperature to standard care to prevent recurrence of foot ulcer is feasible in patients with diabetes in Norway. Home skin temperature monitoring was performed as frequently by the intervention group as usual foot observations in the controls despite the extra effort required. We did not detect a difference in foot ulcer recurrence between groups, but our study may inform future full scale studies.

Trial registration

Clinicaltrials.gov NCT01269502

     

护理干预在胰岛素泵强化治疗中的作用研究

目的：探讨护理干预对临床使用胰岛素泵治疗糖尿病效果的影响。方法：在161例用口服降糖药及常规胰岛素皮下注射进行血糖控制但效果不佳的糖尿病患者使用胰岛素泵治疗过程中,护理人员对其进行心理护理、置泵前告之患者用胰岛素泵治疗的方法、低血糖的预防、输部位的正确选择等全方位护理。结果：在胰岛素泵使用过程中,护理人员全面、细致、持续的干预达到使用的最佳效果。结论：护理干预是糖尿病患者学会正确的自我管理、自我保健知识和泵使用的各种技术的关键,同时也是保证糖尿病患者胰岛素泵治疗顺利进行的基础和关键。     

Turning evidence into recommendations: Protocol of a study guideline development groups

Background

The Accreditation Council on Graduate Medical Education (ACGME) supports chart audit as a method to track competency in Practice-Based Learning and Improvement. We examined whether peer chart audits performed by internal medicine residents were associated with improved documentation of foot care in patients with diabetes mellitus.

Methods

A retrospective electronic chart review was performed on 347 patients with diabetes mellitus cared for by internal medicine residents in a university-based continuity clinic from May 2003 to September 2004. Residents abstracted information pertaining to documentation of foot examinations (neurological, vascular, and skin) from the charts of patients followed by their physician peers. No formal feedback or education was provided.

Results

Significant improvement in the documentation of foot exams was observed over the course of the study. The percentage of patients receiving neurological, vascular, and skin exams increased by 20% (from 13% to 33%) (p = 0.001), 26% (from 45% to 71%) (p < 0.001), and 18% (51%–72%) (p = 0.005), respectively. Similarly, the proportion of patients receiving a well-documented exam which includes all three components – neurological, vascular and skin foot exam – increased over time (6% to 24%, p < 0.001).

Conclusion

Peer chart audits performed by residents in the absence of formal feedback were associated with improved documentation of the foot exam in patients with diabetes mellitus. Although this study suggests that peer chart audits may be an effective tool to improve practice-based learning and documentation of foot care in diabetic patients, evaluating the actual performance of clinical care was beyond the scope of this study and would be better addressed by a randomized controlled trial.     

Unidades de pie diabético en España: conociendo la realidad mediante el uso de un cuestionario

ObjectiveTo ascertain the number of diabetic foot units (DFUs) in Spain, the specialists working in them, and the population covered by them.Material and methodsThe Spanish Group on the Diabetic Foot (SGDF) prepared and agreed a questionnaire based on the recommendations of the 2011 International Consensus on the Diabetic Foot (ICDF). From October to December 2012, the questionnaire was sent to members of three scientific societies formed by professionals involved in the care of patients with diabetes mellitus. Population coverage of the responding centers and DFUs was estimated using the 2012 population census.ResultsSeventy five questionnaires were received, 64 of them from general hospitals, which accounted for 13% of the general hospitals of the National Health System. It was calculated that they provided coverage to 43% of the population. Thirty four centers answered that they had a DFU. Specialized diabetic foot care was only provided to 25% of the population. The number of different professionals working at diabetic foot units was 6.3 ± 2.7. Classification of DFUs based on their complexity was as follows: 5 basic units (14.7%), 20 intermediate units (58.8%), and 9 excellence units (26.5%).ConclusionsThe number of DFUs reported in this study in Spain is low, and allow for foot care of only one out of every four patients with diabetes. Spanish health system needs to improve diabetic foot care by creating new DFUs and improving the existing ones.     

White cell accumulation in dependent legs of patients with venous hypertension: a possible mechanism for trophic changes in the skin

The mechanism by which chronic venous insufficiency and venous hypertension are associated with ulceration of the legs is not yet understood. To investigate this mechanism further accumulation of white cells in the dependent legs of normal volunteers, patients awaiting surgery for simple varicose veins, and patients with chronic venous insufficiency was studied. About 24% fewer white cells than in normal subjects left the dependent foot of patients with venous hypertension, and this trapping of white cells, was reversed when the foot was raised; similar changes were not observed in normal subjects or patients with varicose veins.The trophic skin changes typically seen in patients with venous hypertension may be aggravated by damage caused by the repeated accumulation of white cells in the microcirculation.     

Illness among holidaymakers and the effect on a seaside practice.

Between 1 May and 30 September 1983 a practice of three doctors in the centre of Scarborough conducted 1772 consultations with 1472 temporary residents, 967 (55%) of which were during July and August. The pattern of illness differed considerably from that usually found in general practice, with an excess of minor infections, gastrointestinal upsets, and skin problems comprising 46% of the consultations. Practitioners who care for appreciable numbers of temporary residents should plan their services to match the special needs of holidaymakers. The task of doctors in areas with many visitors would be made easier if patients who are on regular medication or are under surveillance brought with them not only enough drugs for their needs but also a summary of their medical history.     

Effectiveness of focused structural massage and relaxation massage for chronic low back pain: protocol for a randomized controlled trial

Background

Hypertension affects 29% of the adult U.S. population and is a leading cause of heart disease, stroke, and kidney failure. Despite numerous effective treatments, only 53% of people with hypertension are at goal blood pressure. The chronic care model suggests that blood pressure control can be achieved by improving how patients and physicians address patient self-care.

Methods and design

This paper describes the protocol of a nested 2 × 2 randomized controlled trial to test the separate and combined effects on systolic blood pressure of a behavioral intervention for patients and a quality improvement-type intervention for physicians. Primary care practices were randomly assigned to the physician intervention or to the physician control condition. Physician randomization occurred at the clinic level. The physician intervention included training and performance monitoring. The training comprised 2 internet-based modules detailing both the JNC-7 hypertension guidelines and lifestyle modifications for hypertension. Performance data were collected for 18 months, and feedback was provided to physicians every 3 months. Patient participants in both intervention and control clinics were individually randomized to the patient intervention or to usual care. The patient intervention consisted of a 6-month behavioral intervention conducted by trained interventionists in 20 group sessions, followed by 12 monthly phone contacts by community health advisors. Follow-up measurements were performed at 6 and 18 months. The primary outcome was the mean change in systolic blood pressure at 6 months. Secondary outcomes were diastolic blood pressure and the proportion of patients with adequate blood pressure control at 6 and 18 months.

Discussion

Overall, 8 practices (4 per treatment group), 32 physicians (4 per practice; 16 per treatment group), and 574 patients (289 control and 285 intervention) were enrolled. Baseline characteristics of patients and providers and the challenges faced during study implementation are presented. The HIP interventions may improve blood pressure control and lower cardiovascular disease risk in a primary care practice setting by addressing key components of the chronic care model. The study design allows an assessment of the effectiveness and cost of physician and patient interventions separately, so that health care organizations can make informed decisions about implementation of 1 or both interventions in the context of local resources.

Trial registration

ClinicalTrials.gov identifier NCT00201136     

Educational Intervention Increased Referrals to Allopathic Care by Traditional Healers in Three High HIV-Prevalence Rural Districts in Mozambique

Introduction

Delayed uptake of clinical services impedes favorable clinical outcomes in Mozambique. Care is delayed among patients who initiate care with traditional healers; patients with conditions like human immunodeficiency virus (HIV) or tuberculosis are rarely referred to the health system in a timely fashion.

Methods

We conducted a pre-post educational intervention with traditional healers, assessing healer referral rates and HIV knowledge in three rural districts in Zambézia Province.

Results

The median monthly referral rate prior to the intervention was 0.25 patients (interquartile range [IQR]: 0–0.54) compared with a post-intervention rate of 0.34 patients (IQR: 0–0.71), a 35% increase (p = 0.046). A median HIV knowledge score of 67% (IQR: 59–78) was noted 4-months pre-intervention and a median score of 81% (IQR: 74–89) was recorded 2½ months post-intervention (p<0.001). One hundred and eleven healers referred 127 adults, 36 pregnant women, and 188 children to health facilities. Referred patients were most likely to be diagnosed with bronchopneumonia (20% adults; 13% children) and/or malaria (15% adults; 37% children). Of 315 non-pregnant persons referred, 3.5% were tested for HIV and 2.5% were tested for tuberculosis.

Discussion

We engaged traditional healers with some success; referral rates were low, but increased post-intervention. Once seen in the clinics, patients were rarely tested for HIV or tuberculosis, though symptoms suggested screening was indicated. We found increased referral rates through an inexpensive intervention with traditional healers, a viable, cost-effective method of directing patients to health facilities. However, quality improvement within the clinics is necessary before a substantial impact can be expected.     

Determinants of Adherence to Treatment in Hypertensive Patients of African Descent and the Role of Culturally Appropriate Education

Background

In Western countries, better knowledge about patient-related determinants of treatment adherence (medication and lifestyle) is needed to improve treatment adherence and outcomes among hypertensive ethnic minority patients of African descent.

Objective

To identify patient-related determinants of adherence to lifestyle and medication recommendations among hypertensive African Surinamese and Ghanaian patients with suboptimal treatment results (SBP≥140) living in the Netherlands and how culturally appropriate hypertension education (CAHE) influenced those determinants.

Methods

This study analysed data of 139 patients who participated in the CAHE trial. Univariate logistic regression analysis was used to measure the association between patient-related determinants (medication self-efficacy, beliefs about medication and hypertension, social support, and satisfaction with care) and treatment adherence. We also tested whether CAHE influenced the determinants.

Results

Medication self-efficacy and social support were associated with medication adherence at baseline. At six months, more medication self-efficacy and fewer concerns about medication use were associated with improved medication adherence. Self-efficacy was also associated with adherence to lifestyle recommendations at baseline. CAHE influenced patients’ illness perceptions by creating more understanding of hypertension, its chronic character, and more concerns about the associated risks.

Conclusion

In this high-risk population, health care providers can support medication adherence by paying attention to patients’ medication self-efficacy, the concerns they may have about medication use and patients’ perceptions on hypertension. The CAHE intervention improved patients’ perception on hypertension.     

The effect of the boron-based gel on the treatment of diabetic foot ulcers: A prospective,randomized controlled trial

BackgroundChronic ulcers represent impaired healing capacity with high mortality in the elderly or patients with systemic disorders such as diabetes. Boron is an effective agent in wound healing by promoting cell migration and proliferation and reducing inflammation in the wound area. This study aimed to evaluate the therapeutic effect of a sodium pentaborate-based topical formulation compared to control on the treatment of diabetic foot ulcers.MethodsA prospective, double-blind, randomized controlled trial was conducted to apply randomly the topical sodium pentaborate 3% gel or topical conventional remedy (control) by patients diagnosed with diabetic foot ulcers. The 171 eligible participants aged 18–75 years received the allocated medicines twice a day for a month with an allocation ratio of 3:1. Twenty-five days and two months after the end of the trial, participants were reinvestigated for their ulcer condition and any recurrence. Wagner’s classification of diabetic foot ulcers was applied to this purpose (0−5).Results161 participants (57 females, 104 males; mean age: 59.37) completed this study. After the intervention, most participants in the intervention group had a lower ulcer grade than the control group (adjusted mean difference (95% CI): − 0.91 (−1.1 to −0.73); p < 0.001). Moreover, most participants in the intervention group (n = 109 (90.8%)) were treated at a higher rate than the control group (n = 5 (12.2%)) after intervention (adjusted odds ratio (95% CI): 0.008 (0.002–0.029); p < 0.001). There was no case of recurrence in the intervention group while its rate was (n = 2 (40%)) in the control group (p < 0.001).ConclusionThe present study suggests that topical sodium pentaborate gel may help treat and decrease the grade of diabetic foot ulcers and prevent the recurrence of diabetic foot ulcers.     

Evaluación de la realización del cribado del pie diabético en Atención Primaria

AimTo ascertain whether patients with type 2 diabetes are screened for diabetic foot, and to analyze the factors related to patients and centers associated to performance of such screening.Material and methodsA multicenter, epidemiological, cross-sectional study was conducted. The clinical records of 443 patients with type 2 diabetes monitored at Primary Care for at least 12 months were reviewed. Demographic and healthcare variables and characteristics of the primary care center were recorded.ResultsIn the previous year, 51.2% of patients had been trained on foot self-care, 56.4% had undergone foot inspection, 39.5% had been examined with a monofilament, and palpation of peripheral pulses and measurement of the ankle-brachial index were performed in 45.8 and 10.1% of patients, respectively. Diabetic foot screening (inspection, monofilament testing, and palpation of peripheral pulses) was performed in 37% of study patients. Ulcer risk stratification was done in 12.4% of patients. A significant association was found between diabetic foot screening and presence of foot deformities (P < .001), history of neuropathy (P = .005), and history of peripheral artery disease (P < .05). Screening was also associated to some characteristics of the center, such as reception of information about goal achievement (P < .001) and economic incentives for goal attainment (P < .001).ConclusionsCompliance with diabetic foot screening and ulcer risk stratification in patients with type 2 diabetes in Primary Care was poor.     

Efficacy of a Community-Based Physical Activity Program KM2H2 for Stroke and Heart Attack Prevention among Senior Hypertensive Patients: A Cluster Randomized Controlled Phase-II Trial

Objective

To evaluate the efficacy of the program Keep Moving toward Healthy Heart and Healthy Brain (KM2H²) in encouraging physical activities for the prevention of heart attack and stroke among hypertensive patients enrolled in the Community-Based Hypertension Control Program (CBHCP).

Design

Cluster randomized controlled trial with three waves of longitudinal assessments at baseline, 3 and 6 months post intervention.

Setting

Community-based and patient-centered self-care for behavioral intervention in urban settings of China.

Participants

A total of 450 participants diagnosed with hypertension from 12 community health centers in Wuhan, China were recruited, and were randomly assigned by center to receive either KM2H² plus standard CBHCP care (6 centers and 232 patients) or the standard care only (6 centers and 218 patients).

Intervention

KM2H² is a behavioral intervention guided by the Transtheoretical Model, the Model of Personalized Medicine and Social Capital Theory. It consists of six intervention sessions and two booster sessions engineered in a progressive manner. The purpose is to motivate and maintain physical activities for the prevention of heart attack and stroke.

Outcome Measures

Heart attack and stroke (clinically diagnosed, primary outcome), blood pressure (measured, secondary outcome), and physical activity (self-report, tertiary outcome) were assessed at the individual level during the baseline, 3- and 6-month post-intervention.

Results

Relative to the standard care, receiving KM2H² was associated with significant reductions in the incidence of heart attack (3.60% vs. 7.03%, p < .05) and stroke (5.11% vs. 9.90%, p<0.05), and moderate reduction in blood pressure (-3.72mmHg in DBP and -2.92 mmHg in DBP) at 6-month post-intervention; and significant increases in physical activity at 3- (d = 0.53, 95% CI: 0.21, 0.85) and 6-month (d = 0.45, 95% CI: 0.04, 0.85) post-intervention, respectively.

Conclusion

The program KM2H² is efficacious to reduce the risk of heart attack and stroke among senior patients who are on anti-hypertensive medication. Findings of this study provide solid data supporting a formal phase-III trial to establish the effectiveness of KM2H² for use in community settings for prevention.

Trial Registration

ISRCTN Register ISRCTN12608966     

Rehabilitation Aspects of Human Sexuality

The PLISSIT model is a comprehensive program that combines educational strategies with behavioral intervention to integrate human sexuality into the initial rehabilitation of spinal cord-injured persons. Sexuality is treated as a health care issue as important as bowel and bladder care, skin care, psychosocial issues, mobility, self-care and vocational concerns. Patients admitted to the Spinal Cord Injury Program are surrounded by a supportive milieu and an interdisciplinary staff who comfortably incorporate sexuality into discussions about catheter care, positioning, communication styles, assistive devices and so forth. Patients are exposed to a behavioral training program that makes available didactic lectures, group and individual sessions, bibliotherapy, films and opportunities for directed overnight sexual exploration within the hospital. We advocate that sex therapy be integrated into comprehensive rehabilitation programs along with physical therapy occupational therapy, recreation therapy and psychotherapy as an integral and effective form of functional restoration for patients with major physical disabilities.     

Cohorting Dengue Patients Improves the Quality of Care and Clinical Outcome

IntroductionThe increasing incidence of dengue among adults in Malaysia and other countries has important implications for health services. Before 2004, in order to cope with the surge in adult dengue admissions, each of the six medical wards in a university hospital took turns daily to admit and manage patients with dengue. Despite regular in-house training, the implementation of the WHO 1997 dengue case management guidelines by the multiple medical teams was piecemeal and resulted in high variability of care. A restructuring of adult dengue inpatient service in 2004 resulted in all patients being admitted to one ward under the care of the infectious disease unit. Hospital and Intensive Care Unit admission criteria, discharge criteria and clinical laboratory testing were maintained unchanged throughout the study period.ObjectivesTo evaluate the impact of cohorting adult dengue patients on the quality of care and the clinical outcome in a university hospital in Malaysia.MethodsA pre (2003) and post-intervention (2005–6) retrospective study was undertaken.InterventionCohorting all dengue patients under the care of the Infectious Disease team in a designated ward in 2004.ResultsThe number of patients enrolled was 352 in 2003, 785 in 2005 and 1158 in 2006. The evaluation and detection of haemorrhage remained high (>90%) and unchanged throughout the study period. The evaluation of plasma leakage increased from 35.4% pre-intervention to 78.8% post-intervention (p = <0.001) while its detection increased from 11.4% to 41.6% (p = <0.001). Examination for peripheral perfusion was undertaken in only 13.1% of patients pre-intervention, with a significant increase post-intervention, 18.6% and 34.2% respectively, p = <0.001. Pre-intervention, more patients had hypotension (21.5%) than detected peripheral hypoperfusion (11.4%), indicating that clinicians recognised shock only when patients developed hypotension. In contrast, post-intervention, clinicians recognised peripheral hypoperfusion as an early sign of shock. The highest haematocrit was significantly higher post-intervention but the lowest total white cell counts and platelet counts remained unchanged. A significant and progressive reduction in the use of platelet transfusions occurred, from 21.7% pre-intervention to 14.6% in 2005 and 5.2% in 2006 post-intervention, p<0.001. Likewise, the use of plasma transfusion decreased significantly from 6.1% pre-intervention to 4.0% and 1.6% in the post-intervention years of 2005 and 2006 respectively, p<0.001. The duration of intravenous fluid therapy decreased from 3 days pre-intervention to 2.5 days (p<0.001) post-intervention; the length of hospital stay reduced from 4 days pre- to 3 days (p<0.001) post-intervention and the rate of intensive care admission from 5.8% pre to 2.6% and 2.5% post-intervention, p = 0.005.ConclusionCohorting adult dengue patients under a dedicated and trained team of doctors and nurses led to a substantial improvement in quality of care and clinical outcome.     

Development of the Tardivo Algorithm to Predict Amputation Risk of Diabetic Foot

Diabetes is a chronic disease that affects almost 19% of the elderly population in Brazil and similar percentages around the world. Amputation of lower limbs in diabetic patients who present foot complications is a common occurrence with a significant reduction of life quality, and heavy costs on the health system. Unfortunately, there is no easy protocol to define the conditions that should be considered to proceed to amputation. The main objective of the present study is to create a simple prognostic score to evaluate the diabetic foot, which is called Tardivo Algorithm. Calculation of the score is based on three main factors: Wagner classification, signs of peripheral arterial disease (PAD), which is evaluated by using Peripheral Arterial Disease Classification, and the location of ulcers. The final score is obtained by multiplying the value of the individual factors. Patients with good peripheral vascularization received a value of 1, while clinical signs of ischemia received a value of 2 (PAD 2). Ulcer location was defined as forefoot, midfoot and hind foot. The conservative treatment used in patients with scores below 12 was based on a recently developed Photodynamic Therapy (PDT) protocol. 85.5% of these patients presented a good outcome and avoided amputation. The results showed that scores 12 or higher represented a significantly higher probability of amputation (Odds ratio and logistic regression-IC 95%, 12.2–1886.5). The Tardivo algorithm is a simple prognostic score for the diabetic foot, easily accessible by physicians. It helps to determine the amputation risk and the best treatment, whether it is conservative or surgical management.     

Integrated care for diabetes: clinical,psychosocial, and economic evaluation. Diabetes Integrated Care Evaluation Team.

OBJECTIVES--To evaluate integrated care for diabetes in clinical, psychosocial, and economic terms. DESIGN--Pragmatic randomised trial. SETTING--Hospital diabetic clinic and three general practice groups in Grampian. PATIENTS--274 adult diabetic patients attending a hospital clinic and registered with one of three general practices. INTERVENTION--Random allocation to conventional hospital clinic care or integrated care. Integrated care patients seen in general practice every three or four months and in the hospital clinic annually. General practitioners were given written guidelines for integrated care. MAIN OUTCOME MEASURES--Metabolic control, psychosocial status, knowledge of diabetes, beliefs about control of diabetes, satisfaction with treatment, disruption of normal activities, numbers of consultations and admissions, frequency of metabolic monitoring, costs to patients and NHS. RESULTS--A higher proportion of patients defaulted from conventional care (14 (10%)) than from integrated care (4 (3%), 95% confidence interval of difference 2% to 13%). After two years no significant differences were found between the groups in metabolic control, psychosocial status, knowledge, beliefs about control, satisfaction with treatment, unscheduled admissions, or disruption of normal activities. Integrated care was as effective for insulin dependent as non-insulin dependent patients. Patients in integrated care had more visits and higher frequencies of examination. Costs to patients were lower in integrated care (mean 1.70 pounds) than in conventional care (8 pounds). 88% of patients who experienced integrated care wished to continue with it. CONCLUSIONS--This model of integrated care for diabetes was at least as effective as conventional hospital clinic care.