diapositiva 1

1. Quality of Diabetes Care Qualidiab: A DOTA Initiative for Latin America and the Caribbean Juan José Gagliardino CENEXA Center of Experimental and Applied Endocrinology (UNLP – CONICET) PAHO/WHO Collaborating Center La Plata, Argentina

2. No of people with diabetes (millions) EME = Established market economies FSE = Formerly socialist economies of Europe MEC = Middle Eastern Crescent OAI = Other Asia and islands LAC = Latin America and the Caribbean SSA = Sub-Saharan Africa Estimates (1995, 2000) and Predictions (2025) of the Absolute Numbers of People with Diabetes Regional groupings according to World Bank (1993). Source: King H, et al (1998). 1995 2000 2025 60 50 40 30 20 10 0 EME FSE MEC I ndia C hina OAI LAC SSA

3. The Number of People with Diabetes per Age Group (1995, 2025) Source: King H, et al (1998). 1995 2025 50 40 30 20 10 0 120 100 80 60 40 20 0 Developing countries 20-44 45-64 64+ Developed countries 20-44 45-64 64+

4. The Facts Rising burden Declining quality of life The Cause Rise in incidence and prevalence of diabetes and its complications The Reasons Demographic changes Socio-economic changes Industrialization & urbanization Unrecognized diabetes Unhealthy lifestyles The Challenge Implementation of prevention at all levels The Tools Appropriate control of diabetes and its risk factors Education of people with diabetes, the public and healthcare team members Continuous monitoring of impact Modification of interventions to increase their effectiveness Dr. Juan José Gagliardino member of the IDF Taskforce on Diabetes Health Economics

5. Knowledge and skills (health care team) Patients empowerment (education) Accesibility (care, drugs and control devices) Prevention  Complications Better quality of life Q of C Evaluation Adjustments J.J. Gagliardino

6. Qualidiab Focus “ Establish monitoring and control systems using state-of-the-art information technology for quality assurance in diabetes care.”

9. Brasil Argentina (South and Main Collecting Center) Paraguay Colombia (Caribbean Collecting Center) Chile Uruguay QUALIDIAB NET París

10. Characteristics of the Qualidiab Population Age 16-35 years 56-75 years Women DM duration (0-5 years) Known relatives with DM Type 1 (%) 37 (16-41) ---- 49 (36-64) 46 (26-71) 52 (21-80) ---- 56 (53-59) 61 (51-71) 49 (36-70) 43 (36-53) Type 2 (%) Number of cases: Type 1= 1229; type 2 = 12.284; total = 13.513

11. Detection of Complications and Cardiovascular Risk Factors In Type 1 DM µalbuminuria and prot. Triglycerides HDL-cholesterol Total cholesterol Creatinine HbA 1c Retina Blood Pressure Foot care Body weight NO YES (18-66) (33-100) (17-71) (38-83) (49-72) (17-81) (7-76) (79-94) (49-90) (95-100) (0-5) (24-93) (0-83) (28-51) (17-62) (29-83) (0-67) (34-92) (10-51) (6-21)

12. Detection of Complications and Cardiovascular Risk Factors in Type 2 DM µalbuminuria and prot. Triglycerides HDL-cholesterol Total cholesterol Creatinine HbA 1c Retina Blood Pressure Foot care Body weight NO YES (17-48) (60-83) (14-84) (65-88) (17-74) (25-83) (4-71) (96-99) (65-91) (96-100) (0-4) (10-35) (2-4) (29-96) (0-89) (26-93) (10-35) (16-86) (0-42) (51-93)

13. Glycemic and Cardiovascular Risk-factor Control In Type 1 DM <1.7 mmol/L >1.7 mmol/L >1.1 mmol/L <1.1 mmol/L <1.0 mmol/L >5.5 mmol/L <6.5 % >9.5 % <4.4 mmol/L >7.7 mmol/L Fasting glycemia HbA 1c Total cholesterol HDL cholesterol Triglycerides 0 10 20 30 40 50 60 70 (50-84) (11-50) (3-31) (9-74) (22-66) (7-57) (5-26) (13-43) (0-61) (1-64)

14. (25-66) (34-68) (2-45) (8-63) (25-40) (37-77) (2-46) (6-29) (6-42) (28-83) Glycemic and Cardiovascular Risk-factor Control in Type 2 DM Fasting glycemia HbA 1c Total cholesterol HDL- cholesterol Triglycerides

15. (28-79) (21-72) (22-81) (19-78) (14-53) (51-84) (24-47) (53-76) (6-95) (5-94) No Yes Therapeutic Education in Type 1 DM Selfmonitoring Interpretation of s.m. Foot care Hypoglycemic control Member of an association

16. (61-99) (1-39) (54-96) (4-46) (11-52) (48-89) (35-70) (30-65) (6-99) (1-94) No Yes Therapeutic Education in Type 2 DM Selfmonitoring Interpretation of s.m. Foot care Hypoglycemic control Member of an association

17. Associated Cardiovascular Risk Factors in Type 1 DM <1.7 mmol/L >1.7 mmol/L >1.1 mmol/L <1.1 mmol/L <1.0 mmol/L >5.5mmol/L <140/90 >140/90 19-24 <19 Total cholesterol HDL cholesterol Triglycerides BMI Hypertension (50-84) (11-50) (3-31) (9-74) (22-66) (7-57) (7-47) (19-45) (4-43) (46-83)

18. Associated Cardiovascular Risk Factors in Type 2 DM BMI <1.7 mmol/L >1.7 mmol/L >1.1 mmol/L <1.1 mmol/L <1.0 mmol/L >5.5 mmol/L <140/90 >140/90 19-24 >30 (25-66) (34-68) (2-45) (8-63) (25-40) (34-77) (35-44) (52-64) (9-27) (19-54) Triglycerides Total cholesterol HDL- cholesterol Hypertension BMI

19. Hyperglycemia Treatment Only diet Only sulfonylureas Only metformin Associations Insulin : NPH Crystalline Combinations Spec. combinations Injections/day: 1 x 2 x 3 x > 3 x Pump Pen Type 1 Type 2 --- --- --- --- 22 (9-42) 0.3 (0-1) 50 (9-79) 4 (0-16) 5 (0-14) 43 (9-79) 16 (1-30) 9 (0-26) 0.1 (0-0.4) 12 (0-47) 13 (4-29) 33 (17-72) 9 (5-20) 14 (0-33) 14 (3-23) 0.4 (0-2) 7 (1-20) 1 (0-5) 5 (2-7) 12 (3-23) 1 (0-4) 1 (0-1.4) --- 2 (0-8) Values represent average % (range)

20. Treatment of Cardiovascular Risk Factors Hypertension Hyperlipidemia ( cholesterol + triglycerides ) Values represent average % (range); [pathology frequency]. Type 1 14 (10-22) [25] 5 (1-11) [49] 42 (20-48) [60] 16 (4-28) [66] Type 2

21. Frequency of Chronic Complications according to DM Duration COMPLICATION 0-5 6-10 11-20 >20 Years Figures represent average percentage values. Chi 2 for trends p< 0.001; n= 13,513 persons Retinopathy (prolif. - no prolif.) 10.0 20.0 38.0 48.0 Blindness 1.7 2.8 3.2 6.7 Peripheral neuropathy 21.0 29.0 37.0 42.0 ESRD 0.2 0.4 0.7 1.5 AMI (previous + last year) 1.5 1.8 4.3 6.7 CVA (previous + last year) 2.1 3.5 2.9 3.3 Amputations (previous + last year) 1.0 1.4 3.6 7.3

23. Knowledge and skills (health care team) Patients empowerment (education) Accesibility (care, drugs and control devices) Prevention  Complications Better quality of life Q of C Evaluation Adjustments J.J. Gagliardino

25. There should be an education programme to explain to the community the importance of dieting and of striving to overcome sedentarism in order to avoid obesity and prevent the development of diabetes. Also to show the role of these interventions in the control and treatment of that disease. But this type of program should start among physicians. Elliot P. Joslin, 1925

26. The Worldwide Diabetes Epidemic: What can we do about it?

27. Percentage Reduction of the Risk of Diabetic Complications Shown in Recent Studies Sources: (1) = DCCT (1993); (2) = Kumamoto Study (1995); (3) = UKPDS (1998); (4) = HOT (1998); (5) = ´4S´ Study (1997); (6) = Helsinki Heart Study (1987). Strategies Retinopathy Nephropathy Neuropathy Cardiovascular & peripheral vascular disease Myocardial infarction All diabetes-related complications Microvascular disease Cardiovascular disease Heart failure Stroke All diabetes-related complications Diabetes-related deaths Total mortality Coronary heart disease (CHD) mortality Major CHD event Cerebrovascular disease events Type 1 Diabetes ↓ 27%-76%(1) ↓ 34%-57%(1) ↓ 60% Type 2 Diabetes ↓ 40%-65%(2) ↓ 70%(2) ↓ 54%(2) ↓ 16%(3) ↓ 12%(3) ↓ 37%(3) ↓ 51%(4) ↓ 56%(3) ↓ 44%(3) ↓ 24%(3) ↓ 32%(3) ↓ 43%(5) ↓ 34%(6)-36%(5) ↓ 33%(6)-55%(5) ↓ 62%(5) Improved blood glucose control Improved blood pressure control Improved lipid control

28. PROCAMEG Opinion leaders Guidelines Diabetologists from the chapters Teaching training GP s Regular courses

31. Average Results verified in 25 PROCAMEG Courses (n=361) Previous attendance to other courses of diabetes Attendance to Diabetes/Endocrinology Services Prescription of a qualitative meal plan Interconsultation with specialists Glycemia required for oral hypoglycemic agents (OHA) prescription Frequency of OHA prescription Glycemia-HbA 1c required for insulin prescription Diabetological knowledge Before the course (Correct answers) After the course 25 % 15 % 35 % 49 % 148 mg/dl Glibenclamide> metformin>both 230 mg/dl – 8.8 % 45 % 81 %

32. PEDNID LA PEDNID LA Programa de Educación del Diabético No Insulinodependiente de Latinoamérica* *Non-Insulin-Dependent Diabetic Education Programme of Latin America Mexico Costa Rica Brazil Argentina Paraguay Colombia Bolivia Uruguay Cuba Chile

33. Variable Degree of Control* Main Characteristics of the Population Sample Data are means ± SEM (n=446). * Figures correspond to degree of “good” control. Values Sex (women vs men) (%) Age (years) Diabetes duration (years) BMI (kg/m 2 ) SBP (mmHg) DBP (mmHg) FBS (mg/dl) HbA 1c (%) Cholesterol (mg/dl) TG (mg/dl) 54.6 ± 10.1 64.1/35.9 8.0 ± 13 31.5 ± 0.3 137.0 ± 1.0 84.9 ± 0.6 184.0 ± 2.8 8.9 ± 0.1 213.6 ± 2.0 184.8 ± 5.7 - - - (24/25) (140) (90) (<110) (<6.5) (<200) (<150)

34. HbA 1c Body weight SBP - DBP -6mos 0 1 month 4 mos 8 mos 12 mos -6mos 0 1 month 4 mos 8 mos 12 mos -6mos 0 1 month 4 mos 8 mos 12 mos -6mos 0 1 month 4 mos 8 mos 12 mos n = 446 n = 323 * p<0.001 ** p<0.05 FBG n = 446 * p<0.001 ** * * * p<0.001 * *

35. Total Cholesterol Triglycerides -6mos 0 1 month 4 mos 8 mos 12 mos -6mos 0 1 month 4 mos 8 mos 12 mos n = 277 * * p<0.001 n = 237 * * p<0.001

36. Decrease in U$ 62 % Cost estimations were performed considering the mean daily intake of each drug as stated below and the average cost of these drugs in the Argentine market. Annual Changes in Drug Intake and Cost Oral hypoglycemic agent (Glibenclamide, 10 mg/d) Antihypertensive drug (Enalapril, 10 mg/d) Cholesterol lowering drug (Simvastatin, 20 mg /d) TOTAL 339 98 28 465 247470 71540 20440 339450 214 16 - 230 156220 11680 - 167900 37649.02 3457.20 - 41106.30 59640.27 21175.84 27123.88 107939.99 Patients Tablets/year Cost/year (n) (n) (U$) Drug 0 12 months Patients Tablets/year Cost/year (n) (n) (U$)

37. Recent Estimates of the Direct Cost (billion US$ and local currencies [LC]) to the Health-care Sector of Diabetes in Comparison with the Total Health-care Budget Denmark Finland France Germany Italy Japan Spain Sweden United Kingdom United States 0.54 0.46 7.30 10.67 4.50 16.94 2.04 0.88 4.65 60.00 9.12 7.84 121.66 179.36 74.95 282.42 33.93 14.72 76.94 1,007.00 3.8 2.6 45.2 19.7 8,220.0 2,070.0 320.0 7.5 2.9 60.0 64 44 753 331 137,000 34,500 5,330 125 48 1,007 Country Estimated cost of DM (US$) Total health budget (US$) Estimated cost of DM (LC) Total health budget (LC) Source: Adapted from Jönsson (1998). Note: The calculation of US$ sums is based on exchange rates as at 26 May 1999.