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More Than a Case Manager

Edward H. Wagner, MD, MPH
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Group Health Cooperative of Puget Sound; Seattle, WA 98101-1448 Grant Support: In part by the Robert Wood Johnson Foundation. Requests for Reprints: Edward H. Wagner, MD, MPH, Center for Health Studies, 1730 Minor Avenue, Suite 1290, Seattle, WA 98101-1448.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(8):654-656. doi:10.7326/0003-4819-129-8-199810150-00015
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Abundant evidence shows that usual medical care does not meet many of the clinical and educational needs of diabetic patients [12]. The reasons for this lackluster performance are the subject of active debate. Don't primary care providers have the expertise and experience to optimize diabetes care, or are they caring for diabetic patients in acute care systems that are ill suited to meet the complex, ongoing needs of patients with chronic illness? Although the need for more expertise plays some role, the evidence suggests that the system effects are even greater [3]. For example, the Medical Outcomes Study showed that usual specialist primary care for diabetes and hypertension was not substantially better than usual generalist care in the same communities, and neither system was optimal [4]. Recent studies have suggested that specialist-run diabetes clinics achieve better outcomes than usual generalist care [56]. Such clinics, including those in the Diabetes Control and Complications Trial [7], involve much more than specialized physicians. They reorganize care specifically to meet the clinical, educational, and psychosocial needs of diabetic patients.

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