Introduction

Diabetes mellitus is a chronic lifelong disease whose management requires ongoing collaboration among a team of health care providers and the patient. Although primary care physicians (PCPs) provide the majority of diabetes care, they are unable to meet the ongoing and growing demands of diabetes management by themselves, needing instead to be a part of an amplified care system. The health care system is beginning to evolve from its historic orientation toward acute illnesses, but acute care remains the dominant paradigm. Management of complex chronic illnesses is given insufficient attention, with inadequate time for physician-patient interactions, and with diabetes often treated alongside other chronic conditions. It is unrealistic to expect chronic diseases, such as diabetes, to be managed in a health care system designed for acute conditions.

The growing incidence of diabetes has been a driving force behind this supplement, which explores a variety of health care models that are evolving to manage chronic illness in the United States (US). With an estimated 25.8 million US adults and children (8.3% of the population) diagnosed with diabetes and 79 million people with pre-diabetes,¹ establishment of effective diabetes care approaches is a major health care priority. Many Americans are uninsured or underinsured,¹ placing them at potentially devastating economic risk. Consideration of race or ethnicity is also essential in establishing effective health care approaches in the US, ensuring care addresses the unique cultural needs of American Indians and Alaska Natives (with diabetes prevalence rates varying by region, from 5.5% among Alaska Native adults to 33.5% among American Indian adults in southern Arizona), non-Hispanic blacks (12.6%), Hispanics (11.8%), Asian Americans (8.4%), and non-Hispanic whites (7.1%).²

The burden of diabetes is personal, societal, and economic. The ability of the health care system to meet treatment goals of the American Diabetes Association³ and the American Association of Clinical Endocrinologists⁴ is grossly inadequate. Approximately 40% of people with diabetes are not achieving glycated hemoglobin targets⁵ and only an astonishingly low 12.2% of treated patients meet the combined targets for glycated hemoglobin, blood pressure, and cholesterol.⁶ The prevalence of macrovascular and microvascular complications that arise due to suboptimal glycemic control is unacceptable. Heart disease mortality and risk of stroke are both 2–4 times higher in people with diabetes than in the general population. Diabetes is the leading cause of blindness among adults, is a principal cause of kidney failure, and accounts for 60% of nontraumatic lower-limb amputations. The societal and economic impact of diabetes and its complications are no less staggering, with $174 billion in estimated total costs as of 2007 ($116 billion in direct medical costs, and $58 billion in indirect costs, such as disability, work loss, and premature mortality). Factoring in the additional costs of undiagnosed diabetes, pre-diabetes, and gestational diabetes brings the total cost of diabetes in the US in 2007 to $218 billion.²

Given the extent of the problem and the cultural and socioeconomic diversity of people living with diabetes, it is clear that there is no one correct diabetes care model that will address these factors. However, core elements have been defined that should be considered in all. The Chronic Care Model (CCM) developed by Ed Wagner is the most widely recognized approach for improving diabetes care at the levels of the community, organization, practice, and patient.⁷ While disease management programs vary in design and implementation, almost all emphasize 1 or more of the 6 core elements of the CCM as a framework for promoting high-quality chronic disease care and improving outcomes.⁸ The CCM rests on the premise that the combination of an informed, active patient, working with providers who have resources and expertise, leads to productive interactions and improved outcomes.⁹ There is substantial evidence that chronic disease management strategies “achieve better disease control, higher patient satisfaction, and better adherence to guidelines by redesigning delivery systems to meet the needs of chronically ill patients.”¹⁰

While the PCP, acting as an individual, can implement each of the 6 elements of the CCM, it is important to see the elements as components of a comprehensive and coordinated approach to care. Research suggests that the more aspects of the CCM you use, the more likely you are to achieve better process and patient outcomes.¹¹ The 6 core elements are: