de organisatie van de diabeteszorg : een blik in de toekomst dr. frank nobels diabetesteam...
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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 :
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
Better effectiveness of care when : Better effectiveness of care when :
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
Spreeuwenberg, Wolffenbuttel 2005
Costs / QALYCosts / QALY
EfficacyEfficacy
Maastricht transmural diabetes organisation(Matador)
GP
Spreeuwenberg, Wolffenbuttel 2005
Maastricht transmural diabetes organisation(Matador)
internist
Spreeuwenberg, Wolffenbuttel 2005
Maastricht transmural diabetes organisation(Matador)
diabetes nurse
Spreeuwenberg, Wolffenbuttel 2005
Maastricht transmural diabetes organisation(Matador)
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
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
Better effectiveness of care when : Better effectiveness of care when :
Mathieu, Nobels, Peters. KCE report 2006
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
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
Better effectiveness of care when : Better effectiveness of care when :
Mathieu, Nobels, Peters. KCE report 2006
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
ConclusionsConclusions
multifaceted intervention
patient empowerment (education)
shared care with clearly defined profiles and tasks
organised follow-up : sheduled visits, patient tracking, recalls, …
decision support
IT support
quality monitoring
Better effectiveness of care when : Better effectiveness of care when :
Mathieu, Nobels, Peters. KCE report 2006
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
DM-DM-centrumcentrum
ZiekenhuisZiekenhuis
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
DM-DM-centrumcentrum
ZiekenhuisZiekenhuis
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