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Chronic Disease Epidemic –
 The Figures for Diabetes
         Thomas R. Pieber
      Medical University of Graz
          ...
Conflict of Interest

• The invited speaker has or had research co-
  operations with companies producing glucose
  loweri...
Diabetes mellitus – a global burden

• Defined by elevated blood glucose
  • Fasting: ≥7.0 mmol/l (126 mg/dl)
  • Postpran...
Diabetes mellitus type 1

• Autoimmune disease
  leading to absolute
  insulin deficiency
   • Genetic factors
   • Enviro...
Diabetes mellitus type 2

• Impaired insulin action
  and insulin secretion
  •   Genetic factors
  •   Age
  •   Obesity
...
Diabetes mellitus – microvascular
complications
• Caused by hyperglycaemia
• Diabetic nephropathy
  • Diabetes is the lead...
Diabetes mellitus – macrovascular
complications
• Caused by diabetes-associated risk factors
  (hypertension, dyslipidaemi...
Diabetes mellitus – diabetic foot
syndrome
• Caused by diabetic neuropathy, vascular disease
  and inadequate medical mana...
“The Diabetes Paradoxon”

• Diabetes is a complex chronic disease associated
  with devastating late complications
• Drama...
“The Diabetes Paradoxon”

• Health care system
  • Interfaces between caregivers not defined
  • Roles of caregivers not d...
Disease Management Programme

   • Approach to patient care that emphasizes
     coordinated, comprehensive care along the...
What’s inside a DMP? (I)
     Quality Improvement Strategies
  DMAA recommendations for Disease Management
  • Population ...
What’s inside a DMP? (II)
    Quality Improvement Strategies

  Classification of Strategies according to Cochrane
  EPOC ...
Disease Management Programme -
Components

                          Population
                         Identification
  ...
Evidence Based Clinical Care
Pathways and Education Initiative




                                    15
Disease Management Programme –
   The Evidence
The Cochrane EPOC Group – Effect on HbA1c




Shojania, 2006
Chronic Disease Epidemic – the
Figures for Diabetes
     … care along the continuum of disease …

• Increasing prevalence ...
Diabetes Prevention Programme

• Identification of genetic and environmental factors
  leading to diabetes
• Identificatio...
Conclusions

• Diabetes is a complex chronic disease with
  devastating late complications
• Increasing prevalence (type 1...
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Chronic Disease Epidemic – the Figures for Diabetes

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Chronic Disease Epidemic – the Figures for Diabetes. Pieber T. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

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Chronic Disease Epidemic – the Figures for Diabetes

  1. 1. Chronic Disease Epidemic – The Figures for Diabetes Thomas R. Pieber Medical University of Graz Austria
  2. 2. Conflict of Interest • The invited speaker has or had research co- operations with companies producing glucose lowering drugs or other diabetes related products. • Furthermore, the invited speaker was or is consultant or speaker at meetings for companies producing glucose lowering drugs, in many cases a honorarium as or is paid.
  3. 3. Diabetes mellitus – a global burden • Defined by elevated blood glucose • Fasting: ≥7.0 mmol/l (126 mg/dl) • Postprandial or after glucose load: ≥11.1 mmol/l (200mg/dl) • Typical, but non-specific symptoms including thirst, increased urine volume, exhaustion, impaired wound healing, itching • Type 1 diabetes (~10%) – type 2 diabetes (~90%) • Chronic disease without cure • Increasing incidences • Burden of late complications
  4. 4. Diabetes mellitus type 1 • Autoimmune disease leading to absolute insulin deficiency • Genetic factors • Environment • Increasing incidence, doubling of new cases in 2020-2025 • Shift to younger children Harjutsalo, 2008 • Shift to ‘low-risk’ groups Patterson, 2009
  5. 5. Diabetes mellitus type 2 • Impaired insulin action and insulin secretion • Genetic factors • Age • Obesity • Sedentary life style • EU: prevalence of 6-10% • Increase in all age groups (including children) • Epidemics of obesity leads to epidemics of type 2 diabetes (380 Mio in 2025)
  6. 6. Diabetes mellitus – microvascular complications • Caused by hyperglycaemia • Diabetic nephropathy • Diabetes is the leading cause for kidney replacement therapy • DNP can be prevented • Progression of DNP can be halted • Diabetic retinopathy • Diabetes is the leading cause for blindness in adults • DRP can be prevented • Progression of DRP can be halted
  7. 7. Diabetes mellitus – macrovascular complications • Caused by diabetes-associated risk factors (hypertension, dyslipidaemia, hyperglycaemia, microvascular complications) • Diabetes is associated with 2-4x risk of myocardial infarction, heart failure, and stroke • Increased mortality • Prevention and adequate treatment
  8. 8. Diabetes mellitus – diabetic foot syndrome • Caused by diabetic neuropathy, vascular disease and inadequate medical management • Diabetes is the leading cause for amputations of the lower limb (10-20x) • Increased mortality • DFS can be prevented • Progression of DFS can be halted
  9. 9. “The Diabetes Paradoxon” • Diabetes is a complex chronic disease associated with devastating late complications • Dramatic increase in prevalence • Diabetes associated late complications could be prevented or reduced • Diabetes is an expensive disease • Health care systems fail to provide adequate care for citizens with diabetes
  10. 10. “The Diabetes Paradoxon” • Health care system • Interfaces between caregivers not defined • Roles of caregivers not defined, referrals are not organised • Conflict of interest between different providers • Quality of care • Missing or insufficient documentation • Inadequate knowledge or implementation of evidence • Diabetic patient • Lack of patient education • Lack of empowerment
  11. 11. Disease Management Programme • Approach to patient care that emphasizes coordinated, comprehensive care along the continuum of disease and across health care delivery systems • Views patients as entities experiencing the clinical course of a disease Ellrodt et al., JAMA 1997;278(20):1687-1692 Hunter/Fairfield, BMJ 1997;315:50-53
  12. 12. What’s inside a DMP? (I) Quality Improvement Strategies DMAA recommendations for Disease Management • Population identification process • Evidence-based practice guidelines • Collaborative practice model to include physician and support- service providers • Risk identification and matching of interventions with need • Patient self-management education • Process and outcomes measurement, evaluation and management • Routine reporting/feedback loop • Appropriate use of information technology Disease Management Association of America (DMAA), 2002
  13. 13. What’s inside a DMP? (II) Quality Improvement Strategies Classification of Strategies according to Cochrane EPOC (Effective Practice and Organization of Care) Group • Audit and Feedback • Case Management • Team Changes • Electronic Patient Registry • Clinician Reminders • Clinician Education • Facilitated Relay of Clinical Information to Clinicians • Patient Education • Promotion of Self-Management • Patient Reminder Systems • Continuous Quality Improvement Cochrane EPOC Group, 2001
  14. 14. Disease Management Programme - Components Population Identification Patient Evidence Based Empowerment Care Pathways Collaborative practice model Clinician Education Reporting & and Training Feedback loop Evaluation Process Organization, Documentation, Communication Quality Management Information Systems
  15. 15. Evidence Based Clinical Care Pathways and Education Initiative 15
  16. 16. Disease Management Programme – The Evidence The Cochrane EPOC Group – Effect on HbA1c Shojania, 2006
  17. 17. Chronic Disease Epidemic – the Figures for Diabetes … care along the continuum of disease … • Increasing prevalence for type 1 and type 2 diabetes • Doubling in the next 10 – 15 years • Pathophysiology only partly understood • Substantial impact on health care systems in the world • Prevention programmes are urgently needed
  18. 18. Diabetes Prevention Programme • Identification of genetic and environmental factors leading to diabetes • Identification of pathophysiological pathways • Identification of effective prevention measures in randomized controlled trials • Identification of measures for population wide implementation • Evaluation and cost effectiveness
  19. 19. Conclusions • Diabetes is a complex chronic disease with devastating late complications • Increasing prevalence (type 1 and type 2 diabetes) • Late complications can be prevented or reduced • Diabetes is an expensive disease • Disease Management Programmes may help to overcome major deficits in care • Diabetes prevention is of major importance for European health care systems

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