Presentaci

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Symposium on Diabetes Economics São Paulo,
Brazil, 27 September 2004 http//www.paho.org/engl
ish/ad/dpc/nc/dia-alad.htm
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PROPAT
Agreement IOMA-CENEXA
Sponsor PAHO/WHO, SAD, IDF
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Province of Buenos Aires and IOMA

• 14,000,000 inhabitants.
• DM prevalence 7.
• Population covered by IOMA 1,400,000.
• IOMA covers ambulatory care,
• hospitalization, laboratory tests and up to
• 100 of drugs cost.

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Annual per capita Costs People with/without DM
ITEM
DM / No DM
3.7 11.5 1.9 1.6
Medical practices Drugs Laboratory Hospitalization
s
MEAN
4.7
J.J. Gagliardino
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Correlation between Hospitalization and Chronic
Complications
Hospitalizations
127
74
83
176
Chi2 for trend plt0.00001 n 1362
J.J. Gagliardino
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Diabetic Patient Control and Treatment
Profile
J.J. Gagliardino
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Optimizing Funds Expenditure
Annual cost
Clinical Practices Office visits Eye exam
(Ophthalmologist) CV exam (Cardiologist) Laborator
y tests FBG Lipid profile HbA1c Urine
analysis Urinary protein-microalbuminuria TOTAL
(US)
22.656 6.683 4.518 12.008 1.595 33.984 3.408 953
85.805
33.036 3.498 1.926 -3.286
9.606 -27.504 9.108 0 26.384
55.692 10.181 6.444 8.722 11.201 6.480 12.516 953
112.189
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Costs estimation Average yearly performance of
the practice x cost of each practice established
by IOMA x number of patients included in the
sample. Rational model according to ADA 1998
EASD 1998 CDC 1991.
J.J. Gagliardino
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Knowledge and skills (health-care team)
Evaluation
Patients empowerment (education)
Accessibility (care, drugs and control devices)
Q of C
Prevention
Adjustments
? Complications
Better quality of life
J.J. Gagliardino
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Goals (Short term)

• To reduce
• Acute complications requiring hospitalization (KA
  and hypoglycemia)
• Frequency and length of hospitalizations due to
  chronic complications
• Unjustified high rate of annual visits to
  doctors office, laboratory tests and drug
  prescription.
• To increase and improve
• Self-control (clinical and metabolic)
• Knowledge and skills of people with DM
  (empowerment)
• Clinical and metabolic control

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• Decrease
• The negative impact of CV risk factors.
• The incidence of DM-related micro- and macro
  angiopathic events.

Goals (Long Term)
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Procedures

• Care plan with periodic visits to nutritionist,
  cardiologist, ophthalmologist and diabetologist.
• Coverage of laboratory tests for metabolic
  control and early diagnosis of complications.
• Free provision of drugs and elements for
  treatment and self-monitoring.
• Provision of a check-book for annual medical
  practices, laboratory tests and drug
  prescription.
• Grant high priority to careful and periodic
  clinical control.
• Education courses as important part of diabetes
  care.
• Accreditation system for diabetes educators.
• Regular provision of education material to health
  providers and patients.
• Continuous control of care quality
  (clinical, biochemical and therapeutic
  indicators), and satisfaction assessment.

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Continuous Monitoring System Information Sources

• Annual medical record (clinical,
  biochemical and therapeutic parameters
  registries.

• Annual record with patient information.

• Prescriptions from check-book.

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Number of Registered Affiliates with DM
Registered
Estimated DM
Registered
Mar del Plata Tandil Balcarce Trenque Lauquen
Total
714 146 55 338 1253
450 74 54 90 668
63.0 50.7 98.2 26.7 53.3
J.J. Gagliardino
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Registered MDs and Nutritionists
MDs registered
Nutritionists registered
Mar del Plata Tandil Balcarce Trenque Lauquen
Total
5 1 2 1 9
68 13 21 8 110
J.J. Gagliardino
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Characteristics of Registered People
Total n 297
With insulin n 131
Without insulin n 166
58 42 56 16 12 11 62 32 45 11 9 5 1.3 0.7
61 39 49 18 16 12 44 57 42 32 11 10 7 2.3 0.8
56 44 61 11 9 8 56 67 24 55 10 8 4 0.6 0.6
J.J. Gagliardino
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Changes in Medical Procedures Never Done Last Year
Parameter
1 year after
Initial
P value
Foot examination Sensory-motor evaluation Blood-pr
essure control Insulin injection-sites
control Cardiologist (annual control) Ophthalmolog
ist (annual control) Nutritionist Education
courses HbA1c Protein/µalbuminuria (annual)
10 21 1 9 19 9 26 72 11 26
31 33 5 17 37 22 88 91 33 46
0.0000 0.0004 0.001 0.0001 0.0000 0.0000 0.0000 0.
0000 0.0000 0.0000
J.J. Gagliardino
Values are expressed as percentage. (n 297)
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Changes Recorded in Clinical and Biochemical
Parameters
Mean SD (n 297 people with DM.
J.J. Gagliardino
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Annual Hospitalization Rates
J.J. Gagliardino
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Annual Expenditure Profile
Costs per capita (US)
J.J. Gagliardino
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There is one thing stronger than all the armies
of the world and that is an idea whose time has
come.
Victor Hugo
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Expected Attitudes Interventions from General
Practitioners

• Early diagnosis (search for)
• Education and self-care promotion
• Progressive treatment
• Interconsultation

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Courses Performed by SAD Chapters/Areas Period
29/09/98-29/09/00
Only organizations and/or places accredited by
SAD are included. PROCAMEG Chapter Coordinators
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PEDNID-LA

• Aim
• To record and evaluate health-care improvement
  and socioeconomic impact of a structured
  therapeutic education program for people with
  Type 2 DM in Latin America (PEDNID-LA) includes
  10 countries.

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Interactive Model
Patient
Doctor
Understand the problem
Diagnosis
Treatment agreement
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IDF Programs for Action Key Target Areas

• National diabetes programs
• Empowerment of people with diabetes
• Quality of diabetes care
• Further collaboration with WHO
• Research
• Public awareness

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Chapters of the Sociedad Argentina de Diabetes
Salta
Nordeste
Córdoba
Litoral
Mendoza
Atlántico
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Traditional Attention Model
Patient
Doctor
Treatment
Diagnosis
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Economic Cycle of the Disease
Low productivity
Low salaries
More disease
Low quality manpower
Reduced investment in preventive medicine and
health
Malnutrition Education deficit Inadequate housing
Higher health care demand
Disease
From Dr. Horwitz
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Diabetologists
General Practitioners
Health-care team members
People with diabetes their relatives
Community
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Time Shared with DM (Days/Year)
Health Care team (1.3)
Co-workers (80)
Person with DM (365)
Family (285)
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Diagnosis, Control and Treatment of DM
90-95 General Practitioners
5-10 Diabetologists
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PROCAMEG
Opinion leaders
Guidelines
Diabetologists from the chapters
Teaching training
GPs
Regular courses
Training
Pedagogy
Diabetology