Diabetes Care System


To improve diabetes care in the community, several guidelines and diabetes management programs have been developed nationally and locally. The chronic care model is a fine example of a disease management model. It identifies six elements: community resources and policies, health care organisation, self-management support, delivery system design, decision support and clinical information systems. In the ‘the Diabetes Care System (DCS)’ several elements of this chronic care model have been implemented. Briefly, our DCS includes three main elements: firstly, coordination of diabetes care between primary and secondary care, secondly, guidance of caregivers and diabetes patients and thirdly, patient empowerment.

The objective of the DCS is to improve diabetes care by providing the coordination of the sub-regional diabetes care including benchmarking of the main treatment outcomes, and to give feedback to the GPs. Additionally, to provide annual medical examinations for patients, and extensive education by diabetes nurses and dieticians in order to improve patient empowerment.


Nationally we collaborate in the so-called “string of pearls” project, in which several academic centers combine clinical data from diabetes patients to a central database. Regionally there is cooperation with other diabetes care groups. Internationally we contribute to the European project: EUropean Best Indicators through Regional  Outcomes Diabetes (EUBIROD) project. This is a cooperation of 20 regional databases in Europe.


At the beginning of 2009, 5014 diabetes patients were included in the DCS. We analysed results of the DCS as a prospective observational cohort study of patients with diabetes who were included in the DCS was performed. The data collected every year on HbA1c, weight, height, blood pressure, fasting blood glucose, and cardiovascular risk factors were used to evaluate the results. Glycaemic control showed an initial sharp decrease, followed by over-time stabilization during follow-up. The use of insulin therapy and diabetes duration increased. Cardiovascular risk factors improved, with exception of systolic blood pressure. In conclusion, the DCS was successful in improving diabetes care. This implies that disease management might be a major factor in the care of patients with diabetes.

Contact information

Director of the DCS: Prof. dr. Giel Nijpels; website: www.diabetes-zorg.nl