Preventive maintenance care in a diabetes clinic.

discharge from VA hospitals in 1976, comprising about 8 per cent of all discharge diagnoses. A study by the VA Nursing Service in 1977 revealed that there were 34 diabetes nurse practitioner clinics in Veterans Administration hospitals where the major focus was on patient/family teaching. This was second only to 44 hypertension nurse practitioner clinics. Most newly diagnosed and poorly controlled diabetics are taught on a one-to-one basis concerning all aspects of diabetes care, including diet, administration of insulin, and foot care. Individual diet counseling is done by dietitians, with emphasis being placed on achieving and maintaining ideal body weight and on meal planning within the constraints imposed by the physician's diet prescription. At the present time, there is obviously great variation in the quality of diabetes education programs from one VA hospital to another. Whereas non-VA hospitals may look to third party payers for support to establish diabetes education programs, third party support is not available to VA hospitals at present. Part of the key to improving diabetes education programs in VA hospitals is to provide adequate resources in the VA budget to accomplish the mission. These resources ideally would include more physician diabetologists, more diabetes nurse practitioners and dietitians, and more podiatrists. These individuals would need more adequate ambulatory care and education facilities so that they can provide continuing primary care for an identified patient population. Periodic yearly screening for diabetes in all veterans who obtain medical care from the VA would be desirable, so that appropriate therapy could be initiated early in the course of the disease. Such an approach would almost certainly decrease the number of unnecessary hospitalizations related to acute and chronic complications, and this, in turn, would make the therapy of diabetes more cost effective. Health care in the United States is just beginning to remedy its structural and strategic deficiencies that have resulted in inadequate patient education and follow-up care for those with diabetes. Presently available evidence suggests that the Veterans Administration Hospital system has already assumed a leading role in the correction of these deficiencies.