[Heart-diabetes-network--a concept for improved care for diabetic cardiovascular patients following cardiac surgical intervention].

Diabetic patients with heart disease are high risk patients for further vascular complications and therefore need an intensive and multimodal, interdisciplinary intervention. Due to the "segmentation" of medical care into primary care physician, specialists, acute and secondary care (rehabilitation) clinics, the patients will be taken care of on each individual segment with regard to the current requirements and specialties of the care provider. Such--each section, the GP, the cardiologist and the diabetologist, the heart centre and the rehabilitation clinic, represent individual and often strictly separate segments, which each will focus only on the acute problem and will collect (only) data required for the care in their particular segment. A multimodal approach can improve the chronic care and prognosis of these patients, as shown in several studies. The proposed network model should increase multi-disciplinary cooperation of the different levels of health care segments and overcome current barriers. It is thus necessary to provide common guidelines for diagnostic and therapeutic procedures and to improve communication between each individual sector. This could help to improve the secondary prevention in these high risk patients.