Chronic Disease Epidemic –

The Figures for Diabetes

Thomas R. Pieber

Medical University of Graz

Austria

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.

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

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

• Shift to ‘low-risk’ groupsHarjutsalo, 2008

Patterson, 2009

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)

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

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

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

“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

“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

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

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

What’s inside a DMP? (I)Quality Improvement Strategies

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

• Team Changes

• Clinician Reminders

• Facilitated Relay of Clinical Information to Clinicians

• Patient Education

• Patient Reminder Systems

• Continuous Quality Improvement

Cochrane EPOC Group, 2001

• Case Management

• Electronic Patient Registry

• Clinician Education

• Promotion of Self-Management

Disease Management Programme -

Components

Evidence BasedCare Pathways

Evaluation

Clinician Educationand Training

PatientEmpowerment

PopulationIdentification

Collaborative practice model

Reporting &Feedback loop

Process Organization, Documentation, Communication

Quality Management

Information Systems

15

Evidence Based Clinical Care

Pathways and Education Initiative

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 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

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

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