De organisatie van de diabeteszorg : een blik in de toekomst Dr. Frank Nobels diabetesteam O.L.Vrouwziekenhuis Aalst

De organisatie van de diabeteszorg : De organisatie van de diabeteszorg : een blik in de toekomsteen blik in de toekomst

Dr. Frank Nobels

diabetesteam O.L.Vrouwziekenhuis Aalst

DM-DM-centrumcentrum

ZiekenhuisZiekenhuis

RegioRegio

11 inj inj

OADOAD

dietdiet

anno 2006 : 0.5 milj. type 2 diabetics in Belgium

22 inj inj

≥≥33 inj inj

unknownunknown

diabetes centers : 1/10 of known diabetics

GP’s : ≥ 9/10 of known diabetics

good glycemic control is difficult to maintain

UKPDS Group. Lancet 1998;352:837–853.

06

7

8

9

0 3 6 9 12 15

Med

ian

Hb

A1c

(%

)

Years from randomisation

Conventional

Intensive

6.2%=upper limit of normal range

UKPDS Group. Lancet 1998;352:837–853.

06

7

8

9

0 3 6 9 12 15

Med

ian

Hb

A1c

(%

)

Years from randomisation

Conventional

Oral Monotherapy

Oral Combination

Oral + Insulin

Treat to target

Intensive

treat to target concept

Complex Insulin Regimen

from diagnosis until start of insulin therapy : from diagnosis until start of insulin therapy : 5 j HbA1c > 8%5 j HbA1c > 8% 10 j HbA1c > 7%10 j HbA1c > 7%(Brown J, et al. Diabetes Care 2004;27:1535―40)

many new drugs in the pipeline

Healthy lifestyle

Insulin sensitizers

Incretins (oral)Insulin secretagogues

If incretins do not prove to be beta cell protective long term

Inhaled insulin (mealtime)

Incretins (injectable)

Intensive insulin treatment (injected)

Inhaled insulin plus injected insulin (basal)

Healthy lifestyle

Insulin sensitizers (metformin, glitazones, glitazars)

Incretins (oral)

Incretins (injectable)

Insulin secretagogues

Inhaled insulin (mealtime)

Inhaled insulin plus injected insulin (basal)

Intensive insulin treatment (injected)

If incretins prove to be beta cell protective long term

0

10

20

30

40

50

60

<6 6-<7 7-<8 8-<9 9-<10 10+

Updated HbA1c (%)

% In

cid

ence

per

100

0 p

atie

nt

year

s

Myocardialinfarction

Microvasculardisease

Type 2 diabetes

UKPDS 35. BMJ 2000; 321: 405-412.

good glycemic control complications

United Kingdom Prospective Diabetes Study (UKPDS)

x 2x 2

x 10x 10

life style intervention

blood glucose treatment

cardiovascular risk correction

early detection and treatment of complications

multifactorial intervention

STENO-2 study

Gaede et al. NEJM 03;348:383

follow-up 7.8 j

Belgian Health Care Knowledge CentreBelgian Health Care Knowledge Centre

To formulate recommendations on the quality and organisation of care for type 2type 2 diabetes in Belgium, based on :

1. Identification of quality indicators in the literature

2. Analysis of the impact of the organisation of diabetes care on health and non-health outcomes in the evidence-based literature

3. Description of diabetes care organisation in 9 Western countries

http://kce.fgov.be

ConclusionsConclusions

multifaceted intervention

patient empowerment (education)

multidisciplinary care with clearly defined tasks

organised follow-up : sheduled visits, patient tracking, recalls, …

decision support

IT support

quality monitoring Mathieu, Nobels, Peters. KCE report 2006

Better effectiveness of care when : Better effectiveness of care when :






decision support

IT support

quality monitoring


Mathieu, Nobels, Peters. KCE report 2006

GP coordinates care

calls in team members based on medical complexity :1 = GP alone2 = diabetes nurse3 = internist 11

33

Maastricht transmural diabetes organisation(Matador)

Spreeuwenberg, Wolffenbuttel 2005

22


Costs / QALYCosts / QALY

EfficacyEfficacy


GP



internist



diabetes nurse



type 1 en type 2 diabetes

minstens 1 insuline-injectie per dagminstens 1 insuline-injectie per dag

cumuleerbaar met diabetesconventie

enkel voor pat. met diabetespas

educatieeducatie door referentieVPK thuiszorg

ofwel educatie tot zelfzorg (5u) :- 76.60 E (3090 Bf) voor educatie door referentieVPK diabetes - 30.70 E (1240 Bf) voor aanwezigheid van vaste VPK - 2 x 10.20 E (2 x 412 Bf) voor opvolging 2 x / j

ofwel educatie tot inzicht (2u) : - 25.50 E (1030 Bf) door vaste of referentieVPK- 0.25 E (10 Bf) /d voor verdere dagelijks begeleiding

educatie door thuisverpleegkundige

diabetesverpleegkundige in de eerste lijn

Shojania et al. JAMA 2006;296:427-440






decision support

IT support

quality monitoring



klasse generische naam producten

biguaniden metformine Glucophage®, Metformax®, Merck-metformine®

gliniden repaglinide NovoNorm®

sulphonylurea gliclazide Diamicron®, Merck-Gliclazide®

glipizide Glibenese®, Minidiab®

gliquidone Glurenorm®

glibenclamide Bevoren®, Daonil®, Euglucon®

gliclazide L.A. Uni diamicron®

glimepiride Amarylle®

glitazones pioglitazone Actos®

rosiglitazone Avandia®

glucosidase remmers

acarbose Glucobay®

insulines

many ingredientsmany ingredients

MORE THAN 200 DELICIOUS MEALS WITH ONLY 4 I NGREDIENTSMORE THAN 200 DELICIOUS MEALS WITH ONLY 4 I NGREDIENTS

ROAD MAP : glycemic treatmentcontraindication / intolerance for metformin?

no yes

metformin repaglinide

HbA1c > 7.0 %HbA1c > 7.0 %

+ secretagogue : e.g. gluiqidone + glitazonHbA1c > 7.5 %HbA1c > 7.5 %

fasting BG > 150 mg/dl (8.3 mmol/l)

yes no

NPH insulin at bedtime refer for specialist careHbA1c > 7.5 %HbA1c > 7.5 %

refer for specialist care






decision support

IT support

quality monitoring



Data, Data Everywhere - not accessible

CHICHIHospitalSHospitalSMRMR

GPGP

AHP’sAHP’s

Lab Lab DataData

PharmacyPharmacyEye VanEye Van

InvestigationsInvestigations

ScreeningScreening

Linking Data

GPGP HospitalHospital

Eye VanEye Van

PharmacyPharmacy

Lab Lab DataData

CHICHI

InvestigationsInvestigations ScreeningScreening

AHPsAHPs

- the key to seamless care




shared care with clearly defined profiles and tasks


decision support

IT support

quality monitoring



0

1020

30

4050

60

7080

90

100

It’s me !It’s me !It’s me !It’s me !

DiabCare®

0

1020

30

4050

60

7080

90

100That looksThat looks

much much

better!better!

DiabCare®

Al heel wat bouwstenen aanwezig, maar :

- er ontbreken er nog

- gebrek aan structuur

Er staat nog geen huis !Er staat nog geen huis !

In België ?

SHARED CARESHARED CARE

COMMONCOMMON

KULKUL UA/UGUA/UG

CARE MANAGEMENTCARE MANAGEMENT

2005 2007

HEALTH ECONOMIC ANALYSIS HEALTH ECONOMIC ANALYSIS

- Top-down

- Diabetes Support Structure

- Bottom-up

- Using existing health care structures

diabetes intervention projects

Optimalisation Optimalisation of care of care for DM2for DM2



RegioRegiozorgtrajecten

internal medicine

A1 cardio 49D5 pneumo-endo 43D4 gastro 24B1 cardio 22D1 nefro-gastro 19 C7 neuro-onco 16A2 geriatry 14D2 geriatry 16T6 oncology 12A0 psychiatry 3

surgery

C6 cardiovasc. 40C5 cardiovasc. 32A3 cardiovasc./neurosurg. 20C3 urology 14C4 general 12G0 orthopedic 11C1 orthopedic 9A4 gynecology/general 8C2 gynecology 1

hyperglycemic patients in OLV-Aalst

patients on ‘diabetic diet’ / month / ward in 2004

19 % of hospitalised patients19 % of hospitalised patients

27054

63772

145800

0

20000

40000

60000

80000

100000

120000

140000

160000

94 99

2004

bedside BG measurements in OLV-Aalst

.

0 100 200

HO

SP

ITA

L S

UR

VIV

AL

(%

)

0 40 80 120

ICU

SU

RV

IVA

L (%

)

80

90

100

80

90

100

70

ALL PATIENTS

p = 0.005

ALL PATIENTS

p = 0.01

Long-stay patients

p = 0.007Long-stay patients

p = 0.02100

90

80

100

90

80

70

DAYS AFTER INCLUSION DAYS AFTER INCLUSION

0 20 40 60 80 100120 0 50 100 150 200

Intensive

Conventional

Intensive

Conventional

mortality

Van den Berghe et al. NEJM 2001;345:1359

tight BG control in CABG sternitis

Furnary et al. Ann Thorac Surg 1999;67:352– 62

van 2% 0.5%

DIGAMI 1 study : myocardial infarction

total group : 5 y mortality 28 % 28 % (p 0.011)

Malmberg et al. BMJ 97;314:1512

HbA1c 1y

7.1 7.9

11%

44%

26%

9%19%

33%

prognose op lange termijn verbeteren

slecht geregelde diabetes

miskende diabetes

transiënte hyperglycemie



RegioRegiozorgtrajecten

klinisch pad

admission : detection of hyperglycemia/diabetes

iv. insulin infusion

multipel sc. injection system

moving towards discharge

discharge

clinical path : hyperglycemia during hospitalisation

fasting

QA : - BG measurements- effectiveness of protocols

mean BGL (mg/dL)

70

80

90

100

110

120

130

140

150

160

170

induction preCPB CPB1 endCPB postCPB ICU1 ICU4 ICU8 ICU12 ICU16 ICU20 ICU24

Non-Diabetics Diabetics (type 1+2)

n =7437 BGL n= 2352 BGL

mean BG in CABG : perop & ICU (n = 9789)

OLV Aalst 2006

Documents

De organisatie van de diabeteszorg : een blik in de toekomst Dr. Frank Nobels diabetesteam O.L.Vrouwziekenhuis Aalst