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Quality of Diabetes Care Qualidiab: A DOTA Initiative  for  Latin America and the Caribbean  Juan José Gagliardino CENEXA ...
No of people with diabetes (millions) EME = Established market economies FSE = Formerly socialist economies of Europe MEC ...
The Number of People with Diabetes per Age Group (1995, 2025) Source:  King H, et al (1998). 1995 2025 50 40 30 20 10 0 12...
The Facts Rising burden Declining quality of life The Cause Rise in incidence and prevalence of diabetes and its complicat...
Knowledge and skills (health care team) Patients empowerment (education) Accesibility (care, drugs and control devices) Pr...
Qualidiab Focus “ Establish  monitoring  and  control  systems using state-of-the-art information technology for quality a...
<ul><li>Qualidiab Instruments </li></ul><ul><li>Quality indicators </li></ul><ul><li>Basic  information sheet </li></ul><u...
Examples of the Qualidiab Indicators Type of indicator  Outcomes <ul><li>True outcomes </li></ul><ul><li>Intermediate outc...
Brasil Argentina (South and Main Collecting Center) Paraguay Colombia (Caribbean Collecting Center) Chile Uruguay QUALIDIA...
Characteristics of the Qualidiab Population Age 16-35 years 56-75 years Women  DM duration (0-5 years) Known relatives wit...
Detection of Complications and Cardiovascular Risk Factors In Type 1 DM µalbuminuria and prot. Triglycerides HDL-cholester...
Detection of Complications and Cardiovascular Risk Factors in Type 2 DM µalbuminuria and prot. Triglycerides HDL-cholester...
Glycemic and Cardiovascular Risk-factor Control In Type 1 DM <1.7 mmol/L >1.7 mmol/L >1.1 mmol/L <1.1 mmol/L <1.0 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 Control...
(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...
(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 S...
Associated Cardiovascular Risk Factors in Type 1 DM <1.7 mmol/L >1.7 mmol/L >1.1 mmol/L <1.1 mmol/L <1.0 mmol/L >5.5mmol/L...
Associated Cardiovascular Risk Factors in Type 2 DM BMI <1.7 mmol/L >1.7 mmol/L >1.1 mmol/L <1.1 mmol/L <1.0 mmol/L >5.5 m...
Hyperglycemia Treatment Only diet Only sulfonylureas Only metformin Associations Insulin :   NPH   Crystalline   Combinati...
Treatment of Cardiovascular Risk Factors Hypertension  Hyperlipidemia ( cholesterol + triglycerides ) Values represent ave...
Frequency of Chronic Complications according to DM Duration COMPLICATION 0-5 6-10 11-20 >20 Years Figures represent averag...
 
Knowledge and skills (health care team) Patients empowerment (education) Accesibility (care, drugs and control devices) Pr...
EDUCATION Targets Programmes and Contents The community <ul><li>Health promotion </li></ul><ul><li>Risk factors for CVD (r...
There should be an education programme to explain to the community the importance of dieting and of striving to overcome s...
The Worldwide Diabetes Epidemic: What can we do about it?
Percentage Reduction of the Risk of Diabetic Complications Shown in Recent Studies Sources: (1) = DCCT (1993); (2) = Kumam...
PROCAMEG Opinion leaders Guidelines Diabetologists from the chapters Teaching training GP s Regular courses
PROCAMEG Medical Education Knowledge <ul><li>Procedures </li></ul><ul><li>Diagnostic </li></ul><ul><li>Control </li></ul><...
PROCAMEG Evaluation <ul><li>Characteristics, previous training in DM and teaching </li></ul><ul><li>experience of the part...
Average Results verified in 25 PROCAMEG Courses (n=361) Previous attendance to other courses of diabetes Attendance to Dia...
PEDNID LA PEDNID LA Programa de Educación del Diabético No Insulinodependiente de Latinoamérica*  *Non-Insulin-Dependent D...
Variable Degree of Control* Main Characteristics of the Population Sample Data are means ± SEM (n=446).  * Figures corresp...
HbA 1c 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 m...
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 * ...
Decrease in U$ 62 % Cost estimations were performed considering the mean daily intake of each drug as stated below and the...
Recent Estimates of the Direct Cost (billion US$ and local currencies [LC]) to the Health-care Sector of Diabetes in Compa...
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Workshop rpt-5-qualidiab

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Workshop rpt-5-qualidiab

  1. 1. Quality of Diabetes Care Qualidiab: A DOTA Initiative for Latin America and the Caribbean Juan José Gagliardino CENEXA Center of Experimental and Applied Endocrinology (UNLP – CONICET) PAHO/WHO Collaborating Center La Plata, Argentina
  2. 2. No of people with diabetes (millions) EME = Established market economies FSE = Formerly socialist economies of Europe MEC = Middle Eastern Crescent OAI = Other Asia and islands LAC = Latin America and the Caribbean SSA = 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). 1995 2000 2025 60 50 40 30 20 10 0 EME FSE MEC I ndia C hina OAI LAC SSA
  3. 3. The Number of People with Diabetes per Age Group (1995, 2025) Source: King H, et al (1998). 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+
  4. 4. 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
  5. 5. Knowledge and skills (health care team) Patients empowerment (education) Accesibility (care, drugs and control devices) Prevention  Complications Better quality of life Q of C Evaluation Adjustments J.J. Gagliardino
  6. 6. Qualidiab Focus “ Establish monitoring and control systems using state-of-the-art information technology for quality assurance in diabetes care.”
  7. 7. <ul><li>Qualidiab Instruments </li></ul><ul><li>Quality indicators </li></ul><ul><li>Basic information sheet </li></ul><ul><li>Computer programs </li></ul><ul><li>Local quality circles </li></ul><ul><li>LA and C Quality Network </li></ul><ul><li>Continous Quality development </li></ul>
  8. 8. Examples of the Qualidiab Indicators Type of indicator Outcomes <ul><li>True outcomes </li></ul><ul><li>Intermediate outcomes </li></ul><ul><li>Quality of life </li></ul><ul><li>Treatment satisfaction </li></ul><ul><li>Documentation </li></ul><ul><li>Self-monitoring </li></ul><ul><li>Interventions </li></ul>Procedures Example New cases of blindness Proliferative retinopathy HbA 1c, microalbuminuria Anxiety, well being Tests request frequency Feet and eye examination Blood pressure lowering therapy at increased albumin excretion
  9. 9. Brasil Argentina (South and Main Collecting Center) Paraguay Colombia (Caribbean Collecting Center) Chile Uruguay QUALIDIAB NET París
  10. 10. Characteristics of the Qualidiab Population Age 16-35 years 56-75 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
  11. 11. Detection of Complications and Cardiovascular Risk Factors In Type 1 DM µalbuminuria and prot. Triglycerides HDL-cholesterol Total cholesterol Creatinine HbA 1c 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)
  12. 12. Detection of Complications and Cardiovascular Risk Factors in Type 2 DM µalbuminuria and prot. Triglycerides HDL-cholesterol Total cholesterol Creatinine HbA 1c 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)
  13. 13. Glycemic and Cardiovascular Risk-factor Control In 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 HbA 1c 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)
  14. 14. (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 Control in Type 2 DM Fasting glycemia HbA 1c Total cholesterol HDL- cholesterol Triglycerides
  15. 15. (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
  16. 16. (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
  17. 17. Associated Cardiovascular Risk Factors in Type 1 DM <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)
  18. 18. Associated Cardiovascular Risk Factors in Type 2 DM BMI <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
  19. 19. Hyperglycemia Treatment Only diet Only sulfonylureas Only metformin Associations Insulin : NPH Crystalline Combinations Spec. combinations Injections/day: 1 x 2 x 3 x > 3 x Pump Pen 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)
  20. 20. Treatment of Cardiovascular Risk Factors Hypertension Hyperlipidemia ( cholesterol + triglycerides ) Values represent average % (range); [pathology frequency]. Type 1 14 (10-22) [25] 5 (1-11) [49] 42 (20-48) [60] 16 (4-28) [66] Type 2
  21. 21. Frequency of Chronic Complications according to DM Duration COMPLICATION 0-5 6-10 11-20 >20 Years Figures represent average percentage values. Chi 2 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
  22. 23. Knowledge and skills (health care team) Patients empowerment (education) Accesibility (care, drugs and control devices) Prevention  Complications Better quality of life Q of C Evaluation Adjustments J.J. Gagliardino
  23. 24. EDUCATION Targets Programmes and Contents The community <ul><li>Health promotion </li></ul><ul><li>Risk factors for CVD (risk groups) </li></ul><ul><li>Message to the diabetic population </li></ul>The health-care team <ul><li>Health-care organization according to the </li></ul><ul><li>levels of complexity </li></ul><ul><li>Minimal acceptable standards for </li></ul><ul><li>health-care and treatment </li></ul><ul><li>Continuous education programmes </li></ul>People with DM and their relatives
  24. 25. 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
  25. 26. The Worldwide Diabetes Epidemic: What can we do about it?
  26. 27. Percentage Reduction of the Risk of Diabetic Complications Shown 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 Retinopathy Nephropathy Neuropathy Cardiovascular & peripheral vascular disease Myocardial infarction All diabetes-related complications Microvascular disease Cardiovascular disease Heart failure Stroke All diabetes-related complications Diabetes-related deaths Total mortality Coronary heart disease (CHD) mortality Major CHD event Cerebrovascular 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) Improved blood glucose control Improved blood pressure control Improved lipid control
  27. 28. PROCAMEG Opinion leaders Guidelines Diabetologists from the chapters Teaching training GP s Regular courses
  28. 29. PROCAMEG Medical Education Knowledge <ul><li>Procedures </li></ul><ul><li>Diagnostic </li></ul><ul><li>Control </li></ul><ul><li>Treatment </li></ul><ul><li>Attitudes </li></ul><ul><li>With patient </li></ul><ul><li>With other specialists </li></ul>DIABETOLOGY SOCIAL BEHAVIOUR
  29. 30. PROCAMEG Evaluation <ul><li>Characteristics, previous training in DM and teaching </li></ul><ul><li>experience of the participants </li></ul><ul><li>Degree of satisfaction (referred to the training course) </li></ul><ul><li>Program impact upon: </li></ul><ul><li> knowledge (multiple choice) </li></ul><ul><li> attitudes * </li></ul><ul><li>results * </li></ul><ul><li>* Follow up of a randomized patients sample </li></ul>
  30. 31. Average Results verified in 25 PROCAMEG Courses (n=361) Previous attendance to other courses of diabetes Attendance to Diabetes/Endocrinology Services Prescription of a qualitative meal plan Interconsultation with specialists Glycemia required for oral hypoglycemic agents (OHA) prescription Frequency of OHA prescription Glycemia-HbA 1c required for insulin prescription Diabetological 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 %
  31. 32. PEDNID LA PEDNID LA Programa de Educación del Diabético No Insulinodependiente de Latinoamérica* *Non-Insulin-Dependent Diabetic Education Programme of Latin America Mexico Costa Rica Brazil Argentina Paraguay Colombia Bolivia Uruguay Cuba Chile
  32. 33. Variable Degree of Control* Main Characteristics of the Population Sample Data are means ± SEM (n=446). * Figures correspond to degree of “good” control. Values Sex (women vs men) (%) Age (years) Diabetes duration (years) BMI (kg/m 2 ) SBP (mmHg) DBP (mmHg) FBS (mg/dl) HbA 1c (%) Cholesterol (mg/dl) TG (mg/dl) 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)
  33. 34. HbA 1c 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 ** p<0.05 FBG n = 446 * p<0.001 ** * * * p<0.001 * *
  34. 35. 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 * * p<0.001 n = 237 * * p<0.001
  35. 36. Decrease in 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 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$) Drug 0 12 months Patients Tablets/year Cost/year (n) (n) (U$)
  36. 37. 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 Denmark Finland France Germany Italy Japan Spain Sweden United Kingdom United States 0.54 0.46 7.30 10.67 4.50 16.94 2.04 0.88 4.65 60.00 9.12 7.84 121.66 179.36 74.95 282.42 33.93 14.72 76.94 1,007.00 3.8 2.6 45.2 19.7 8,220.0 2,070.0 320.0 7.5 2.9 60.0 64 44 753 331 137,000 34,500 5,330 125 48 1,007 Country Estimated cost of DM (US$) Total health budget (US$) Estimated cost of DM (LC) Total health budget (LC) Source: Adapted from Jönsson (1998). Note: The calculation of US$ sums is based on exchange rates as at 26 May 1999.

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