[Disease management for diabetes mellitus to prevent the onset and progression of complications].

We developed a new critical pathway technique and an outbound-inbound call center system. The former is to support general physicians to care for outpatients with diabetes mellitus according to practice guidelines. We employed the "Overlay method" to develop personalized optimal critical pathways. Our overview critical pathways consist of basic sheets for regular examinations and optional sheets on which the kinds and frequencies of medical examinations are determined according to many parameters, such as methods of treatment, the severity of diabetic complications, and knowledge levels. The critical pathway is continually modified according to the change in the patient's condition. The latter is to maintain and enhance the treatment motivation of outpatients. Call center agents collect medical information, making outgoing calls using a questionnaire about the patient's health status and diabetic complications as well as receiving incoming calls. When patients do not visit on the appointment date, call center agents arrange the next consultation to prevent treatment dropout. These systems are now under evaluation in a clinical trial of outpatients with diabetes mellitus.