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ORGANIZATION OF CARE : SPECIFICITIES OF THE MEDITERREAN REGION. THE EXPERIENCE OF ALGERIA . A. BOUDIBA. HUC ALGIERS. 2381 741Km 2 85% Sahara 32. 400.000 population (2004) 52,7% < 25 years 5,1% > 65 years. GBR: Gross birth rate GDR: Gross death rate NGR: Natural growth rate. - PowerPoint PPT Presentation
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ORGANIZATION OF CARE :ORGANIZATION OF CARE : SPECIFICITIES OF THE SPECIFICITIES OF THE
MEDITERREAN REGION.MEDITERREAN REGION.THE EXPERIENCE OF ALGERIATHE EXPERIENCE OF ALGERIA..
A. BOUDIBA. HUC ALGIERSA. BOUDIBA. HUC ALGIERS
2381 741Km2
85% Sahara
32. 400.000 population (2004)
52,7% < 25 years 5,1% > 65 years
GBRGBR GDRGDR NGR (Pour 1000)NGR (Pour 1000)
19801980 43,943,9 11,811,8 32,132,1
19901990 31,031,0 6,06,0 2525
20042004 20,420,4 4,54,5 15,815,8
• GBR: Gross birth rate
• GDR: Gross death rate
• NGR: Natural growth rate
48 Wilayas / 548 Dairas / 1541 municipalities
185 Health districts (100 / 200.000 people)
13 HUC 1252 3964 Private sector
SHC Health centers health care (privately owned
rooms sector strong
growth : specialists (58%)
DIABETES CARE MANAGEMENT DIABETES CARE MANAGEMENT
GOVERNMENT ENTITIES « Awareness »• Health Department/Prevention Direction/national diabetes committee• National program against non transmissible diseases• 8 risk factors (tobacco, alcohol drinking, obesity, sedentariness,
, high blood pressure, hypercholesterolemia, diet)
TREATMENT « Problem of networks »
PRIMARY LEVEL SECONDARY LEVEL TERTIARY LEVELHealth Centers Diabetics Homes HUC General Physicians Polyclinics Regional Hospitals
Technical Equipments not sufficient Basic Specialists
Private Sector
Diabetes
SOCIAL
• Social care security (Free medical care / Reimbursement…)
• Associations / National Diabetes Federation
• Social protection and Solidarity Department.
« Economic transition »
FORMATION - RESEARCH« Diabetes and vascular Risk option »
• Formation Centers : Endocrinology, Diabetology, Internal Medicine
• Research : - Clinical Epidemiology :Many post graduate oriented towards
diabetes
- Fundamentals : University of Sciences and Technology (biology/
animal physiology : Experimental model …Psammomys obesus )
- Immunology…
• Financing sources insufficient : SRNA (Scientific Researches National Agency),
Universities, Health Ministry).
RISK FACTORS ASSOCIATED WITH RISK FACTORS ASSOCIATED WITH TRANSMISSIBLE DISEASES TRANSMISSIBLE DISEASES **
Mostaganem (M) (2140) 4136 Sétif (S) (1996)
MM SS T(%)T(%)
TobaccoTobacco 23.423.4 2828 25.625.6
AlcoholAlcohol 8.18.1 4.24.2 6.26.2
Fruits/vegetablesFruits/vegetables< 5parts< 5parts
60.660.6 49.949.9 55.355.3
SedentarinessSedentariness 3131 11.811.8 21.621.6
0besity0besity 20.920.9
DiabetesDiabetes 5.95.9 8.88.8 7.37.3
socio-eco level. socio-eco level. - Low - Low
- Average- Average - High - High
42.142.150.950.97.37.3
26.926.960.560.512.612.6
34.634.655.555.59.99.9
**
* Methodology « Step wise OMS ». 2004 - Known = 2.5% - Screened = 4.8 % ** - 5.5% (25 – 54 years) - 13.7% (55 – 60 years) ID. R. MALEK, 2001
DIETETICSDIETETICS
• Dieteticians very insufficient ? • National inquiry TAHINA (Transition Health Impact in North Africa)*
Feculents (3.84) Bread 2.14 Potatoes 0.91 Pasta 0.63 Couscous 0.3
Dairy products 1.28
Vegetables 0.83
Sugar products/Sodas 0.62
Fruits 0.53
Meats products/proteins Eggs 0.43Meats 0.19Poultry 0.15Fish 0.14 (< 0.06) Country side
Fats Olive oil 0.44Others 1.3
* National Public Health Institute 2006
HEALTH NETWORKS ORGANISATION HEALTH NETWORKS ORGANISATION 3 REGIONAL POLES 3 REGIONAL POLES
WEST / 18 Wilayas (W) CENTRE / 12 W EAST / 18 W
1 NETWORK / HEALTH SECTOR* ~ 100.000/200.000/
Screening (2006) / AG** - BP Care offer Education FormationWest (~ 190.000 ~ 10% - 18.3% Access / Availability RecommendationsCentre (~ 141.000 ~ 11% - 19.2% Easy pathway UniformisationEast (~ 90.000 ~ 7.7%
COMPONENTS : - Health professionals / Doctors – Paramedics - Patients of the health district STRUCTURES : - Referential ─ HUC / Internal Medicine - Diabetology - Reception sites ─ Diabetes home / Polyclinics… OBJECTIVES : ~ 3 years
- Phase I ─ Implementation patient’s file sharing (minimal data)
- Phase II ─ Evaluation of medical Audits practices and behaviors. - Phase III ─ Optimization Recommendations
* M. BROURI. Algiers Reevaluation **AG : Abnormal Glycemia
PRIMARY PREVENTIONPRIMARY PREVENTION « Determination of a predictives score »*« Determination of a predictives score »*
n = 1500n = 1500Priliminary results (297)**Priliminary results (297)**
NGT (175)
IFG(9)
IGT(61)
DM(52)
Age (years) 46.61(10.05)
51.21(11.23)
(53.62)(10.40)
< 0.001
Heredity 33 67% 65 < 0.01
BMI 23.11 28.81(5.74)
28.64(4.55)
< 0.001
HBP (%) 11.42 31% 34% < 0.001
Metab. Syndrome. 17% 56% 65% < 0.001
Triglyceride (g/l) 1.25(0.68)
1.38(0.72)
1.55(0.76)
< 0.01
HDL (g/l) 0.48(0.10)
0.50(0.11)
0.45(0.12)
ALAT (UI/l) 17.05(9.07)
48.24(10.7)
50.88(13.81)
< 0.001
Walking > 30’/d 1.12(0.79)
0.82(0.56)
0.86(0.6)
Green vegetables / Week 6.00(2.48)
6.95(3.03)
6.67(3.72)
Fruits / Week 6.44(3.29)
5.51(2.45)
6.65(3.22)
Fish / Week 1.42(1.09)
1.17(0.43)
1.32(1.19)
* LINDRSTRÖM J. TUOMILEHTO J. The diabetes risk score. A practical tool to predict type 2 diabetes risk. D. care 2003, 26, 725-731.* Implementation of the national type 2 diabetes prevention TUOMILEHTO J. IDF 2006. ** M. AZZOUZ, A. BOUDIBA. Algiers.
PREVENTION : PREVENTION : RISK FACTORS OF THE RISK FACTORS OF THE GESTATORY DIABETESGESTATORY DIABETES
Profile of the Algerian Pregnant woman with GD risk*Profile of the Algerian Pregnant woman with GD risk*
Controls (300) Cases (150)
Anterior macrosomia 7% 33% +(OR=3.67 ; 1.91<IC<7.05)
BMI > 25 14% 31% +(OR=3.10 ; 1.91<IC<5.03)
Low social economic level
9% 26% +(OR=2.53 ; 1.34<IC<4.47)
Family diabetes history
25% 58% +(OR=1.94 ; 1.38<IC<3.53
Multiparity ≥ 3 40% 69% +(OR=1.88 ; 1.15<IC<3.08)
Age > 30 / ATCD T2D / Insulinotherapy during pregnancy Decisive factors of the persistance of post-partum diabetes. Obesity / Age > 30 / Insulinotherapy during pregnancy showing GD high risk factors of recurency*** S. MIMOUNI – A. BOUDIBA.** M. BACHAOUI – M. BELHADJ.
PREVENTION : DIABETIC FOOTPREVENTION : DIABETIC FOOT • Problem : - 10% - 30% hospitalizations : 55% bed occupancy rate
- Amputations : 2001-2005 (decrease 31%) - Podologists / Revascularition surgery : do not exist ?
• Prevention recommendations – education : reinforcement at all levels • Projections I PRELIMINARY RESULTS* PODOSCOPY Organ risk normal F Hallow Flat Anatomic condition 54% 38% 8% RECOMMANDATIONS Good Average BadFootwear 30% 52% 18%Hygiene 63% 32% 5%Education Level 21% 46% 33% Of the patient
Regular foot 39%Check up
LÉSION STATUS
Clinic N = 48% Neurologic = 32% Ischemic = 6% Mixte = 14%EchoDoppler N = 42% Pathologic = 58% - Atherosclerosis 44%
- Mediacalcosis 39% - Atheromatosis + Stenosis 7% Projections II (Algerian Society of Vascular Medecine**) prevention / Preservation treatment / Decrease of amputations.* S. AOUICHE, A. BOUDIBA – Diabetology Algiers. ** M. BROURI – UHC Birtraria Internal Medecine Algiers.
vulnerability score
SAMEV creation
MEDICAL CARE /SECONDARY LEVELMEDICAL CARE /SECONDARY LEVEL
Exemple «Diabetic Home»Exemple «Diabetic Home»~ 30 000 Check up/year~ 30 000 Check up/year
Clinical practice evaluation 2005 Clinical practice evaluation 2005
• HbA1c > 1/an 30% 1f/an 70%
• Retinal screening 85%• ECG 70%• Lipids (TC – Trig.) 95%• HDL/LDL 20%• Micro albuminuria 21%• Vascular Doppler 22%• Foot care 30% • Educators/dieteticians : 8 (2 sessions/day)• Psychologists : 2
TYPE 2 DIABETES MEDICAL CARE EVALUATIONTYPE 2 DIABETES MEDICAL CARE EVALUATION«Diabetics Home in Algeria»«Diabetics Home in Algeria»
Number 2001 2005Number 2001 2005 934 1689934 1689Average follow up (year) 9.39 Average follow up (year) 9.39 6.86 6.91 6.86 6.91 6.65 6.65Overweight BMI > 25-30 35% 43%Overweight BMI > 25-30 35% 43%Obesity > 30 25% 29% Obesity > 30 25% 29% BP 50.8% 67% BP 50.8% 67% SBP - 13.44 SBP - 13.44 2.19 2.19 DBP - 7.87 DBP - 7.87 1.16 1.16Cardiovascular events 22% 29% Cardiovascular events 22% 29% Abnormal ECG 20% 36% Abnormal ECG 20% 36% Retinopathy 33% 27% Retinopathy 33% 27% Périphéric neuropathy 45.8% 54%Périphéric neuropathy 45.8% 54%Néphropathy 27% 24% Néphropathy 27% 24% HbA1c ≤ 7%HbA1c ≤ 7%Trig > 1.5 g/l 29% 28% Trig > 1.5 g/l 29% 28% T Chol. > 2 g/l 32% 34% T Chol. > 2 g/l 32% 34% Insulin secretor agents 65% 49% Insulin secretor agents 65% 49% Biguanid Biguanid InsulinothérapyInsulinothérapyCEICEI
ARAII ARAII -- 16% 16%
.blocking 21% 26% .blocking 21% 26% Diurétics 11% 21% Diurétics 11% 21% Calcium inhibitors 17% 23%Calcium inhibitors 17% 23%Lipid lowering drugsLipid lowering drugs
cms/Hg
11% 23%11% 23%
28% 39%
42% 51%
11% 27%
27% 35%
5400
Hea
lth A
ssoc
iatio
ns
To sum up, they consist, inter alia, into thecreation of a «national fund» dedicated to ill People; to listen to and evaluate the waiting time to access medical care; to bring closer quality care services to citizens where they live, to repertoriate ; chronic ill people in order to be able to respond with quality medical care and allow for real treatment opportunities to happen. Dj. K
To sum up, they consist, inter alia, into thecreation of a «national fund» dedicated to ill People; to listen to and evaluate the waiting time to access medical care; to bring closer quality care services to citizens where they live, to repertoriate ; chronic ill people in order to be able to respond with quality medical care and allow for real treatment opportunities to happen. Dj. K
25 mars 200725 mars 2007
BETWEEN RECOMMENDATIONS ..… AND MEDICAL PRACTICE
PATIENT PHYSICIAN HEALTH SYSTEM
- Socio- économic level - Cost - Complexity- Priorities
- Motivation- Rémuneration work place - Education - Attitudes
- Organisation - Transition Public/Private- Ressources - Spécialized staff- Equipments
Therapeutic alliance= Bypass / supress hurdles*- Care offers / Easy way - Realistic messages / simple / rehabilitation of mediterranean diet - General physician rehabilitation. - Appropriate recommendations / act on modifiable constraints**
* Euro-Obstacles * VENKAT NARRAYAN KM et Al. Translation research for chronic disease. The case of diabetes. Diabetes care 23, 12, 1794-98, 2000.** H. ALBERTI, N. BOUDRISSA. Primary care of patients with diabetes mellitus in Tunisia qualitative study of barriers and facilitators to care (IDF 2006).
DISEASE
- Diet/ exercice- Métabolic Syndrom« anti hyperglycemic objectives drown- Multidisciplinairy Relays with little efficiency
« Death is anavoidable, but a lasting
bad health is not»
FID 2006.