Effects of protocol-driven care versus usual outpatient clinic care on survival rates in patients with type 2 diabetes

Am J Manag Care. 2003 Sep;9(9):606-15.


Objective: To determine whether clinical outcomes in patients with type 2 diabetes were improved by protocol-driven care in a Diabetes Centre compared with usual outpatient care.

Study design: Descriptive analysis of a prospective cohort.

Patients and methods: During a median 7-year observational period, 91 patients with type 2 diabetes and no cardiovascular or renal complications were monitored by a nurse and a diabetologist in a clinical trial setting according to a structured protocol. Another 81 patients with comparable clinical characteristics were monitored by generalists at the medical clinic in the same hospital. Clinical end points, defined as death and cardiovascular and renal events, were evaluated in 1997 by review of case records.

Results: Patients receiving structured care had lower mortality (relative risk [RR] = 0.21; 95% confidence interval [CI] = 0.07, 0.65; P = .006) than the usual-care group, as well as a lower incidence of combined clinical end points (RR = 0.43; 95% CI = 0.22, 0.84; P = .01). In the usual-care group, patients who had no monitoring of glycosylated hemoglobin or plasma lipid levels during the entire observational period (8.6%) had a 14.6-fold (P < .01) and 15.7-fold (P < .01) increased risk of death and combined clinical end points, respectively, compared with those who had at least one measurement (60.5%).

Conclusion: Management by protocol-driven care model improved survival and clinical outcomes in patients with type 2 diabetes. Definitive studies are required to confirm these findings and compare the cost effectiveness of these care models.

Publication types

  • Clinical Trial
  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Antihypertensive Agents / therapeutic use*
  • Blood Glucose / analysis
  • Cholesterol, HDL / blood
  • Cholesterol, LDL / blood
  • Clinical Protocols*
  • Diabetes Mellitus, Type 2 / complications
  • Diabetes Mellitus, Type 2 / mortality*
  • Disease Management*
  • Drug Monitoring
  • Enalapril / therapeutic use*
  • Female
  • Glycated Hemoglobin / analysis
  • Hong Kong / epidemiology
  • Humans
  • Hypertension / complications
  • Hypertension / drug therapy*
  • Male
  • Middle Aged
  • Nifedipine / therapeutic use*
  • Outpatient Clinics, Hospital / standards*
  • Survival Analysis
  • Treatment Outcome


  • Antihypertensive Agents
  • Blood Glucose
  • Cholesterol, HDL
  • Cholesterol, LDL
  • Glycated Hemoglobin A
  • Enalapril
  • Nifedipine