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

DM- centrum Ziekenhuis Regio

1 inj OAD diet anno 2006 : 0.5 milj. type 2 diabetics in Belgium 2 inj ≥3 inj unknown 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– Median HbA 1c (%) Years from randomisation Conventional Intensive 6.2%=upper limit of normal range

UKPDS Group. Lancet 1998;352:837– Median HbA 1c (%) 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 :  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

<66-<77-<88-<99-<1010+ Updated HbA 1c (%) % Incidence per 1000 patient years Myocardial infarction Microvascular disease Type 2 diabetes UKPDS 35. BMJ 2000; 321: good glycemic control  complications  United Kingdom Prospective Diabetes Study (UKPDS) x 2 x 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 Centre type 2 To formulate recommendations on the quality and organisation of care for type 2 diabetes in Belgium, based on :  Identification of quality indicators in the literature  Analysis of the impact of the organisation of diabetes care on health and non-health outcomes in the evidence-based literature  Description of diabetes care organisation in 9 Western countries

Conclusions 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 :

Conclusions 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 : Mathieu, Nobels, Peters. KCE report 2006

GP coordinates care calls in team members based on medical complexity : 1 = GP alone 2 = diabetes nurse 3 = internist 1 3 Maastricht transmural diabetes organisation (Matador) Spreeuwenberg, Wolffenbuttel

Costs / QALY Efficacy 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 dag cumuleerbaar met diabetesconventie enkel voor pat. met diabetespas educatie educatie door referentieVPK thuiszorg ofwel educatie tot zelfzorg (5u) : E (3090 Bf) voor educatie door referentieVPK diabetes E (1240 Bf) voor aanwezigheid van vaste VPK -2 x E (2 x 412 Bf) voor opvolging 2 x / j ofwel educatie tot inzicht (2u) : E (1030 Bf) door vaste of referentieVPK E (10 Bf) /d voor verdere dagelijks begeleiding educatie door thuisverpleegkundige

diabetesverpleegkundige in de eerste lijn Shojania et al. JAMA 2006;296:

Conclusions 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 : Mathieu, Nobels, Peters. KCE report 2006

klassegenerische naamproducten biguanidenmetformineGlucophage ®, Metformax ®, Merck-metformine ® glinidenrepaglinideNovoNorm ® sulphonylureagliclazideDiamicron ®, Merck-Gliclazide ® glipizideGlibenese ®, Minidiab ® gliquidoneGlurenorm ® glibenclamideBevoren ®, Daonil ®, Euglucon ® gliclazide L.A.Uni diamicron ® glimepirideAmarylle ® glitazonespioglitazoneActos ® rosiglitazoneAvandia ® glucosidase remmers acarboseGlucobay ®

insulines

many ingredients MORE THAN 200 DELICIOUS MEALS WITH ONLY 4 I NGREDIENTS

ROAD MAP : glycemic treatment contraindication / intolerance for metformin? no yes metformin repaglinide HbA1c > 7.0 % + secretagogue : e.g. gluiqidone + glitazon HbA1c > 7.5 % fasting BG > 150 mg/dl (8.3 mmol/l) yes no NPH insulin at bedtime refer for specialist care HbA1c > 7.5 % refer for specialist care

Conclusions 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 : Mathieu, Nobels, Peters. KCE report 2006

Data, Data Everywhere - not accessible CHI HospitalS MR GP AHP’s Lab Data Pharmacy Eye Van Investigations Screening

Linking Data GP Hospital Eye Van Pharmacy Lab Data CHIInvestigations Screening AHPs - the key to seamless care

Conclusions 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 : Mathieu, Nobels, Peters. KCE report 2006

It’s me ! DiabCare ®

That looks muchbetter! DiabCare ®

Al heel wat bouwstenen aanwezig, maar : - er ontbreken er nog - gebrek aan structuur Er staat nog geen huis ! In België ?

SHARED CARE COMMON KULUA/UG CARE MANAGEMENT HEALTH ECONOMIC ANALYSIS - Top-down - Diabetes Support Structure - Bottom-up - Using existing health care structures diabetes intervention projects Optimalisation of care for DM2

DM- centrum Ziekenhuis Regio zorgtrajecten

internal medicine A1 cardio 49 D5 pneumo-endo 43 D4 gastro 24 B1 cardio 22 D1 nefro-gastro 19 C7 neuro-onco 16 A2 geriatry 14 D2 geriatry 16 T6 oncology 12 A0psychiatry3 surgery C6cardiovasc. 40 C5 cardiovasc. 32 A3 cardiovasc./neurosurg. 20 C3 urology 14 C4 general 12 G0 orthopedic11 C1 orthopedic 9 A4 gynecology/general8 C2 gynecology 1 hyperglycemic patients in OLV-Aalst patients on ‘diabetic diet’ / month / ward in % of hospitalised patients

bedside BG measurements in OLV-Aalst

HOSPITAL SURVIVAL (%) ICU SURVIVAL (%) ALL PATIENTS p = ALL PATIENTS p = 0.01 Long-stay patients p = Long-stay patients p = DAYS AFTER INCLUSION 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  28 % total group : 5 y mortality  28 % (p 0.011) Malmberg et al. BMJ 97;314:1512 HbA1c 1y 7.1  % 44% 26% 9% 19% 33%

prognose op lange termijn verbeteren slecht geregelde diabetes miskende diabetes transiënte hyperglycemie

DM- centrum Ziekenhuis Regio zorgtrajecten 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

n = 7437 BGL n = 2352 BGL mean BG in CABG : perop & ICU (n = 9789) OLV Aalst 2006