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After many decades of relative therapeutic stagnation since the initial discovery of insulin, followed by some modifications on its structure and only having sulfonylureas and biguanides for many years, the last decade has seen a surge in new therapeutic options for the management of diabetes. The results of the United Kingdom Prospective Diabetes Study and Kumamoto study indicate the need for aggressive glycemic control and the slow inexorable clinical deterioration associated with type 2 diabetes overtime. The propensity for weight gain and hypoglycemia are the two major limitations that subcutaneous insulin and sulfonylureas have been particularly prone to. The newer antidiabetic medications and those on the horizon attempt to address these limitations. GLP-1 agonists and the DPP-IV inhibitors exploit the innate incretin system to improve glycemia while promoting satiety and weight management. Like GLP-1 related compounds, pramlintide offers the potential to address postprandial hyperglucagonemia associated with type 2 diabetes only limited by the multiple injections and gastrointestinal side effects. The glitazars offer the hope ofa new approach to diabetes care addressing not just glycemia, but dyslipidemia and other components of the metabolic syndrome, though the side effect profile remains a major unknown. The INGAP peptide represents the holy grail of diabetes care as it offers the potential of a new paradigm: that of islet regeneration and potential for a cure. But at this stage, with no human data available, it remains highly speculative. Beyond these and other novel agents being developed to meet the challenge of the worldwide epidemic of diabetes, the central place of insulin in diabetes care cannot be forgotten. In view of this the continued efforts of improvement in insulin delivery, kinetics and action have spurred such innovations as the various inhaled insulins and new insulin analogues. There is cause for guarded optimism and excitement about the years ahead. There is reason to expect that despite the growing burden of diabetes worldwide, we will be better equipped to manage it and its comorbidities and prevent its onset and possibly even cure it.

Health care expenditures have been the fastest growing component of the US federal budget over the last 5 years, far outpacing the rate of inflation. Limited dollars and the enormous pressures for balancing federal expenditures stimulated the failed Presidential Health Care Reform Task Force of 1993. Despite the failure of this mammoth effort to restructure health care delivery, the movement stimulated and facilitated market reforms. 2 The move to managed care, with its emphasis on prevention and control of expenditures, has been a persuasive and overriding consideration in health care over the last 4 years. 39 It is likely that this trend will continue with the requirement that health care delivery systems demonstrate efficiency, cost containment, and adequacy of outcomes. To this end, a cottage industry has arisen to develop means of assessing outcomes and providing a score card to be utilized by both consumers and payors to determine provider choice. This article reviews health care outcomes as they apply to the treatment of diabetes. In particular, it reviews concepts of outcomes assessment, providing examples of those currently being implemented, and the available data on various quality measures of diabetes care. An attempt is made to critique existing outcomes research that pertains to diabetes and to provide a framework for needed data collection and analysis in the future. The field of health care outcomes is defined as the longitudinal observational study relating clinical practice and its costs to measurable changes in the well-being and health of patients. 14,47 The results of these inquiries have a critical role in decision analysis for the development of clinical guidelines, in quality measurement with subsequent bench marking of physician performance, in cost-effectiveness analysis, and, ultimately, in health care policy determination. Within this framework, outcomes studies provide a means of monitoring health care in specialized populations (i.e., the chronically ill, the elderly, and the uninsured), as well as a means of evaluating different systems of health care delivery and making comparisons of generalist versus specialist care. 11 As data become available, they are quickly publicized and applied to public policy. 45 Conclusions based on these data are clearly dependent on the quality of the data collection, its reliability, and accuracy, together with appropriately applied analytical techniques.