Workshop rpt-5-qualidiab

Quality of Diabetes Care

Qualidiab: A DOTA Initiative for Latin America and the Caribbean

Juan José Gagliardino

CENEXACenter of Experimental and Applied Endocrinology (UNLP – CONICET)

PAHO/WHO Collaborating Center

La Plata, Argentina

199520002025

60

50

40

30

20

10

0EME FSE MEC India China OAI LAC SSA

No of people withdiabetes (millions)

EME = Established market economiesFSE = Formerly socialist economies of EuropeMEC = Middle Eastern CrescentOAI = Other Asia and islandsLAC = Latin America and the CaribbeanSSA = Sub-Saharan Africa

Estimates (1995, 2000) and Predictions (2025)of the Absolute Numbers of People with Diabetes

Regional groupings according to World Bank (1993).

Source: King H, et al (1998).

The Number of People with Diabetesper Age Group (1995, 2025)

1995 2025

50

40

30

20

10

0

120

100

80

60

40

20

0

Developing countries

20-44 45-64 64+

Developed countries

20-44 45-64 64+

Source: King H, et al (1998).

The Facts

Rising burden Declining quality of life

The Cause

Rise in incidence and prevalence of diabetes and its complications

The Reasons

Demographic changes

Socio-economic changes

Industrialization & urbanization

Unrecognized diabetes

Unhealthy lifestyles

The Challenge

Implementation of prevention at all levels

The Tools

Appropriate control of diabetes and its risk factors

Education of people with diabetes, the public and healthcare team members

Continuous monitoring of impact

Modification of interventions to increase their effectiveness

Dr. Juan José Gagliardino member of the IDF Taskforce on Diabetes Health Economics

Knowledge and skills (health care team)

Patients empowerment

(education)

Accesibility (care, drugs and control devices)

Prevention

↓ Complications

Better quality of life

J.J. Gagliardino

Qualidiab Focus

“Establish monitoring and control systems using state-of-the-art information

technology for quality assurance in diabetes care.”

Qualidiab Instruments

Quality indicators

Basic information sheet

Computer programs

Local quality circles

LA and C Quality Network

Continous Quality development

Examples of the Qualidiab Indicators

Example

New cases of blindness

Proliferative retinopathy

HbA1c, microalbuminuria

Anxiety, well being

Tests request frequency

Feet and eye examination

Blood pressure lowering therapy at increased albumin excretion

Type of indicator

Outcomes•True outcomes

•Intermediate outcomes

•Quality of life

•Treatment satisfaction

•Documentation

•Self-monitoring

•Interventions

Procedures

Brasil

Argentina(South and Main Collecting

Center)

Paraguay

Colombia(Caribbean Collecting Center)

Chile

Uruguay

París

Characteristics of the Qualidiab Population

Age 16-35 years56-75 years

Women

DM duration (0-5 years)

Known relatives with DM

Type 1 (%)

37 (16-41)----

49 (36-64)

46 (26-71)

52 (21-80)

----56 (53-59)

61 (51-71)

49 (36-70)

43 (36-53)

Type 2 (%)

Number of cases: Type 1= 1229; type 2 = 12.284; total = 13.513

0 10 20 30 40 50 60 70 80 90 100

Peso corporal

Examen pies

Control PA

Control retina

Control HbA1c

Control creatinina

Control col. total

Control col. HDL

Control triglic.

Control µalbum. y protein.

NO YES

Detection of Complications and Cardiovascular Risk FactorsIn Type 1 DM

µalbuminuria and prot.

Triglycerides

HDL-cholesterol

Total cholesterol

Creatinine

HbA1c

Retina

Blood Pressure

Foot care

Body weight

NO YES

(18-66)

(33-100)

(17-71)

(38-83)

(49-72)

(17-81)

(7-76)

(79-94)

(49-90)

(95-100)

(0-5)

(24-93)

(0-83)

(28-51)

(17-62)

(29-83)

(0-67)

(34-92)

(10-51)

(6-21)

0 10 20 30 40 50 60 70 80 90 100

Peso corporal

Examen pies

Control PA

Control retina

Control HbA1c

Control creatinina

Control col. total

Control col. HDL

Control triglic.

Control µalbum. y protein.

No detección Detección

Detection of Complications and Cardiovascular Risk Factorsin Type 2 DM

µalbuminuria and prot.

Triglycerides

HDL-cholesterol

Total cholesterol

Creatinine

HbA1c

Retina

Blood Pressure

Foot care

Body weight

NO YES

(17-48)

(60-83)

(14-84)

(65-88)

(17-74)

(25-83)

(4-71)

(96-99)

(65-91)

(96-100)

(0-4)

(10-35)

(2-4)

(29-96)

(0-89)

(26-93)

(10-35)

(16-86)

(0-42)

(51-93)

0 10 20 30 40 50 60 70

>7.7 mmol/L

<4.4 mmol/L

>9.5 %

<6.5 %

>5.2 mmol/L

<5.2 mmol/L

<1.1 mmol/L

>1.1 mmol/L

>1.7 mmol/L

<1.7 mmol/L

Glycemic and Cardiovascular Risk-factor ControlIn Type 1 DM

<1.7 mmol/L

>1.7 mmol/L

>1.1 mmol/L

<1.1 mmol/L

<1.0 mmol/L

>5.5 mmol/L

<6.5 %

>9.5 %

<4.4 mmol/L

>7.7 mmol/L

Fasting glycemia

HbA1c

Total cholesterol

HDL cholesterol

Triglycerides

0 10 20 30 40 50 60 70

(50-84)

(11-50)

(3-31)

(9-74)

(22-66)

(7-57)

(5-26)

(13-43)

(0-61)

(1-64)

0 10 20 30 40 50 60

>7.7 mmol/L

<4.4 mmol/L

>9.5 %

<6.5 %

>5.5 mmol/L

<1,0 mmol/L

<1.1 mmol/L

>1.1 mmol/L

>1.7 mmol/L

<1.7 mmol/L (25-66)

(34-68)

(2-45)

(8-63)

(25-40)

(37-77)

(2-46)

(6-29)

(6-42)

(28-83)

Glycemic and Cardiovascular Risk-factor Controlin Type 2 DM

Fasting glycemia

HbA1c

Total cholesterol

HDL- cholesterol

Triglycerides

0 10 20 30 40 50 60 70 80

Miembro asociación

Control hipogluc.

Cuida sus pies

Interpreta automon.

Realiza automon.

SI NO

(28-79)(21-72)

(22-81)(19-78)

(14-53)(51-84)

(24-47)(53-76)

(6-95)(5-94)

No Yes

Therapeutic Education in Type 1 DM

Selfmonitoring

Interpretation of s.m.

Foot care

Hypoglycemic control

Member of an association

0 10 20 30 40 50 60 70 80

Miembro asociación

Control hipogluc.

Cuida sus pies

Interpreta automon.

Realiza automon.

SI NO

(61-99)(1-39)

(54-96)(4-46)

(11-52)

(48-89)

(35-70)(30-65)

(6-99)(1-94)

No Yes

Therapeutic Education in Type 2 DM

Selfmonitoring

Interpretation of s.m.

Foot care

Hypoglycemic control

Member of an association

Associated Cardiovascular Risk Factors in Type 1 DM

0 10 20 30 40 50 60 70

<19 y >30

19-24

>140/90

<140/90

>5.2 mmol/L

<5.2 mmol/L

<1.1 mmol/L

<1.1 mmol/L

>1.7 mmol/L

<1.7 mmol/L<1.7 mmol/L

>1.7 mmol/L

>1.1 mmol/L

<1.1 mmol/L

<1.0 mmol/L

>5.5mmol/L

<140/90

>140/90

19-24

<19

Total cholesterol

HDL cholesterol

Triglycerides

BMI

Hypertension

(50-84)

(11-50)

(3-31)

(9-74)

(22-66)

(7-57)

(7-47)

(19-45)

(4-43)

(46-83)

Associated Cardiovascular Risk Factors in Type 2 DM

BMI

0 10 20 30 40 50 60

<19 y >30

19-24

>140/90

<140/90

>5.2 mmol/L

<5.2 mmol/L

<1.1 mmol/L

<1.1 mmol/L

>1.7 mmol/L

<1.7 mmol/L<1.7 mmol/L

>1.7 mmol/L

>1.1 mmol/L

<1.1 mmol/L

<1.0 mmol/L

>5.5 mmol/L

<140/90

>140/90

19-24

>30

(25-66)

(34-68)

(2-45)

(8-63)

(25-40)

(34-77)

(35-44)

(52-64)

(9-27)

(19-54)

Triglycerides

Total cholesterol

HDL- cholesterol

Hypertension

BMI

Hyperglycemia Treatment

Only dietOnly sulfonylureasOnly metforminAssociationsInsulin : NPH

Crystalline Combinations Spec. combinations

Injections/day: 1 x 2 x 3 x > 3 x

PumpPen

Type 1 Type 2

------------

22 (9-42)0.3 (0-1)50 (9-79)4 (0-16)5 (0-14)43 (9-79)16 (1-30)9 (0-26)

0.1 (0-0.4)12 (0-47)

13 (4-29)33 (17-72)

9 (5-20)14 (0-33)14 (3-23)0.4 (0-2)7 (1-20)1 (0-5)5 (2-7)

12 (3-23)1 (0-4)

1 (0-1.4)---

2 (0-8)

Values represent average % (range)

Treatment of Cardiovascular Risk Factors

Hypertension

Hyperlipidemia(cholesterol + triglycerides)

Type 1

14 (10-22) [25]

5 (1-11) [49]

42 (20-48) [60]

16 (4-28) [66]

Type 2

Values represent average % (range); [pathology frequency].

Frequency of Chronic Complicationsaccording to DM Duration

COMPLICATION0-5 6-10 11-20 >20

Years

Figures represent average percentage values. Chi2 for trends p< 0.001; n= 13,513 persons

Retinopathy (prolif. - no prolif.) 10.0 20.0 38.0 48.0

Blindness 1.7 2.8 3.2 6.7

Peripheral neuropathy 21.0 29.0 37.0 42.0

ESRD 0.2 0.4 0.7 1.5

AMI (previous + last year) 1.5 1.8 4.3 6.7

CVA (previous + last year) 2.1 3.5 2.9 3.3

Amputations (previous + last year) 1.0 1.4 3.6 7.3

People with DM

Health care providers

Community

Health care purchesersHealth care

policy makers

Industry

Knowledge and skills (health care team)

Patients empowerment

(education)

Accesibility (care, drugs and control devices)

Prevention

↓ Complications

Better quality of life

J.J. Gagliardino

EDUCATION

Targets Programmes and Contents

The community• Health promotion• Risk factors for CVD (risk groups)• Message to the diabetic population

The health-care team

• Health-care organization according to the levels of complexity• Minimal acceptable standards for health-care and treatment

• Continuous education programmesPeople with DM

and their relatives

There should be an education programme to

explain to the community the importance of dieting

and of striving to overcome sedentarism in order to

avoid obesity and prevent the development of

diabetes. Also to show the role of these interventions

in the control and treatment of that disease.

But this type of program should start among

physicians.

Elliot P. Joslin, 1925

The Worldwide Diabetes Epidemic:

What can we do about it?

Percentage Reduction of the Risk of Diabetic ComplicationsShown in Recent Studies

Sources: (1) = DCCT (1993); (2) = Kumamoto Study (1995); (3) = UKPDS (1998); (4) = HOT (1998); (5) = ´4S´ Study (1997); (6) = Helsinki Heart Study (1987).

Strategies

RetinopathyNephropathyNeuropathyCardiovascular & peripheralvascular diseaseMyocardial infarctionAll diabetes-relatedcomplications

Microvascular diseaseCardiovascular diseaseHeart failureStrokeAll diabetes-relatedcomplicationsDiabetes-related deaths

Total mortalityCoronary heart disease (CHD)mortalityMajor CHD eventCerebrovascular disease events

Type 1 Diabetes

↓27%-76%(1)↓34%-57%(1)↓60%

Type 2 Diabetes

↓40%-65%(2)↓70%(2)

↓54%(2)↓16%(3)

↓12%(3)

↓37%(3)↓51%(4)↓56%(3)↓44%(3)

↓24%(3)↓32%(3)

↓43%(5)

↓34%(6)-36%(5)↓33%(6)-55%(5)↓62%(5)

Imp

rove

d bl

ood

gluc

ose

cont

rol

Impr

oved

blo

odpr

essu

re c

ontr

olIm

pro

ved

lipid

cont

rol

PROCAMEG

Opinion leaders Guidelines

Diabetologists from the chapters Teaching training

GPs Regular courses

PROCAMEG

Medical Education

Knowledge

Procedures• Diagnostic

• Control

• TreatmentAttitudes• With patient

• With other specialists

DIABETOLOGY SOCIAL BEHAVIOUR

PROCAMEG

Evaluation

Characteristics, previous training in DM and teaching

experience of the participants

Degree of satisfaction (referred to the training course)

Program impact upon: knowledge (multiple choice) attitudes *

results *

*Follow up of a randomized patients sample

Average Results verified in 25 PROCAMEG Courses(n=361)

Previous attendance to other courses of diabetesAttendance to Diabetes/Endocrinology ServicesPrescription of a qualitative meal planInterconsultation with specialistsGlycemia required for oral hypoglycemic agents(OHA) prescriptionFrequency of OHA prescription

Glycemia-HbA1c required for insulin prescriptionDiabetological knowledge Before the course(Correct answers) After the course

25 %15 %35 %49 %

148 mg/dl

Glibenclamide>metformin>both

230 mg/dl – 8.8 %45 %81 %

Programa de Educación del Diabético No Insulinodependiente

de Latinoamérica*

Mexico

Costa Rica

Brazil

Argentina

Paraguay

Colombia

Bolivia

Uruguay

Cuba

Chile

*Non-Insulin-Dependent Diabetic Education Programme of Latin America

Variable Degree of Control*

Main Characteristics of the Population Sample

Data are means ± SEM (n=446). * Figures correspond to degree of “good” control.

Sex (women vs men) (%)

Age (years)

Diabetes duration (years)

BMI (kg/m2)

SBP (mmHg)

DBP (mmHg)

FBS (mg/dl)

HbA1c (%)

Cholesterol (mg/dl)

TG (mg/dl)

Values

54.6 ± 10.1

64.1/35.9

8.0 ± 13

31.5 ± 0.3

137.0 ± 1.0

84.9 ± 0.6

184.0 ± 2.8

8.9 ± 0.1

213.6 ± 2.0

184.8 ± 5.7

-

-

-

(24/25)

(140)

(90)

(<110)

(<6.5)

(<200)

(<150)

HbA1c

Body weight SBP - DBP

-6mos 0 1 month 4 mos 8 mos 12 mos -6mos 0 1 month 4 mos 8 mos 12 mos

-6mos 0 1 month 4 mos 8 mos 12 mos -6mos 0 1 month 4 mos 8 mos 12 mos

n = 446

n = 323* p<0.001

80

81

82

83

84

85

86

Time-period

kg

** p<0.05

150

160

170

180

190

200

Time-period

mg/d

l

FBG n = 446* p<0.001

7,5

8,0

8,5

9,0

9,5

Time-period

%

85

95

105

115

125

135

145

155

Time-period

mm

Hg

SBP DBP

**

*

*

* p<0.001

*

*

Total Cholesterol Triglycerides

-6mos 0 1 month 4 mos 8 mos 12 mos -6mos 0 1 month 4 mos 8 mos 12 mos

n = 277

205

215

225

235

245

Time-period

mg/

dl

*

* p<0.001

160

185

210

235

260

Time-period

mg/

dl

n = 237

*

* p<0.001

Oral hypoglycemic agent(Glibenclamide, 10 mg/d)

Antihypertensive drug(Enalapril, 10 mg/d)

Cholesterol lowering drug(Simvastatin, 20 mg /d)

TOTAL

339

98

28

465

247470

71540

20440

339450

214

16

-

230

156220

11680

-

167900

37649.02

3457.20

-

41106.30

59640.27

21175.84

27123.88

107939.99

Patients Tablets/year Cost/year (n) (n) (U$)Drug

0 12 months

Patients Tablets/year Cost/year (n) (n) (U$)

Decreasein U$

62 %

Cost estimations were performed considering the mean daily intake of each drug as stated below and the average cost of these drugs in the Argentine market.

Annual Changes in Drug Intake and Cost

Recent Estimates of the Direct Cost (billion US$ and local currencies [LC])to the Health-care Sector of Diabetes

in Comparison with the Total Health-care Budget

DenmarkFinlandFranceGermanyItalyJapanSpainSwedenUnited KingdomUnited States

0.540.467.30

10.674.50

16.942.040.884.65

60.00

9.127.84

121.66179.36

74.95282.42

33.9314.7276.94

1,007.00

3.82.6

45.219.7

8,220.02,070.0

320.07.52.9

60.0

6444

753331

137,00034,500

5,330125

481,007

CountryEstimatedcost of DM

(US$)

Total healthbudget(US$)

Estimatedcost of DM

(LC)

Total healthbudget

(LC)

Source: Adapted from Jönsson (1998).Note: The calculation of US$ sums is based on exchange rates as at 26 May 1999.