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11-year data of the working group for structured
diabetes therapy in Germany (ASD) Evaluated
education and treatment centers for type 1
diabetes reduce the frequency of severe
hypoglycemic events by 50 while improving HbA1c
of patients with intensive insulin therapy A.
Sämann, MD U.A. Müller, MD, MSc Dept. of
Internal Medicine III Friedrich-Schiller-Universit
y Jena, Germany
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Diabetes Control and Complication Trial
N Engl J Med 329 1993977-986.
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Epidemiology of severe hypoglycemia in the DCCT.
The DCCT Research Group. Am J Med 1991
Apr90(4)450-9 Comment in Am J Med. 1992
Mar92(3)339-40
In the DCCT, intensive treatment of IDDM
increased the frequency of severe hypoglycemia
relative to conventional therapy. Intensive
treatment may cause even more frequent severe
hypoglycemia when applied to less selected and
less motivated populations in the clinical
practice setting.
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ASD Arbeitsgemeinschaft für Strukturierte
Diabetestherapie der DDG
Problem
It seemed to be inevitable that the improvement
of blood glucose control by means of intensified
insulin therapy leads to an increase of severe
hypoglycemic events in type 1 diabetes (DCCT
1994).
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ASD Arbeitsgemeinschaft für Strukturierte
Diabetestherapie der DDG
Question
Does the participation of patients with type 1
diabetes in structured and evaluated Diabetes
Teaching and Treatment Programmes (DTTP) for
intensified insulin therapy reduce the frequency
of serious hypoglycaemic events while lowering
Hba1c?
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ASD Arbeitsgemeinschaft für Strukturierte
Diabetestherapie der DDG
Data source
Analysis of selection-free 11 year data of the
working group for structured diabetes therapy in
Germany (ASD).
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ASD Arbeitsgemeinschaft für Strukturierte
Diabetestherapie der DDG 2002
About the ASD

• Founded in 1992 by diabetologists and diabetes
  nurses of primary care hospitals
• Aim continuous evaluation and improvement of
  structured diabetes care in Germany
• Method quality seal for proven outcome quality
  in accredited diabetes centres (validity 3 years)

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ASD Arbeitsgemeinschaft für Struktuierte
Diabetestherapie der DDG 2002
Prerequisite for receiving the quality seal of
the ASD

• Unselected sample (n30) of all type 1 diabetes
  patients with data (HbA1c, number of severe
  hypoglycaemic and ketoacidotic events)
  12 months prior and after participation in the
  programme (DTTP)
• Public presentation of data on the annual meeting

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ASD Arbeitsgemeinschaft für Struktuierte
Diabetestherapie der DDG 2002
Adjusting HbA1c
Relative Hba1c absolute Hba1c / mean
normal of healthy
subjects Mean normal
HbA1c of healthy subjects 1.0 (2 SD upper
lower reference range / 2)
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ASD Arbeitsgemeinschaft für Struktuierte
Diabetestherapie der DDG 2002
Definition of severe hypoglycaemic event

Condition which requires injection of glucose or
glucagon. Hypoglycaemic events which were
successful treated with oral glucose ingestion
were not counted! Source ASD information
bulletin (www.med.uni-jena.de/asd)
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ASD Arbeitsgemeinschaft für Struktuierte
Diabetestherapie der DDG 2002
Method
7635 ASD data sets (collected 1992 - 2002) were
included in the analysis Adjusted Hba1c and
number of severe hypoglycemic events at
intervention and at follow-up were analyzed
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ASD Arbeitsgemeinschaft für Struktuierte
Diabetestherapie der DDG 2002
Results

• Mean relative Hba1c at intervention 1,62 vs.
• 1,44 at follow-up (plt0,001)
• (adjusted to DCCT 8,1 vs. 7,2)
• Number of severe hypoglycemic events at
• intervention 0,39 vs. 0,15 events per patient
  years
• at follow-up (plt0,001)
• Mean normal HbA1c of healthy subjects 1.0

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ASD Arbeitsgemeinschaft für Struktuierte
Diabetestherapie der DDG 2002
Subgroup analysis HbA1c
Mean normal HbA1c of healthy subjects 1.0
Each subgroup consists of a sample of 763
patients. Group 1 includes all samples with
lowest HbA1c values Group 10 highest HbA1c
samples, respectively.
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ASD Arbeitsgemeinschaft für Struktuierte
Diabetestherapie der DDG 2002
Subgroup analysis Severe Hypoglycaemia
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ASD Arbeitsgemeinschaft für Struktuierte
Diabetestherapie der DDG 2002
Conclusions
Reducing Hba1c by means of intensive insulin
therapy in type 1 diabetes is considered to lead
to an increase in severe hypoglycemic events. In
contrast, population based data in Germany over
recent 11 years show that the participation in a
structured Diabetes Teaching and Treatment
Programme (DTTP) for type 1 diabetes in an
ASD-certified diabetes centre reduces both Hba1c
and number of severe hypoglycemic events.
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Ende
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ASD Arbeitsgemeinschaft für Struktuierte
Diabetestherapie der DDG 2002
Results
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