Italy
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Diabetes:
a global problem,
a national problem
What can Italy do? In Italy,
250-300,000 people are diagnosed with diabetes each year
70-80,000 people suffer heart attacks due to diabetes each year
Over 20,000 people experience kidney failure each year due to diabetes
5-6,000 people will have limbs amputated due to complications of diabetes
Nearly 1 million people have diabetes but haven’t yet been diagnosed,
and so are receiving no treatment
We can change diabetes…
We can prevent diabetes for most people…
We can control diabetes in those who are diagnosed… We can prevent much of the suffering linked to diabetes… We can help people with diabetes to live long, healthy lives…
But we need to act now…
This report will provide you with key information to engage with one of the key health debates of the 21st century.
“…a silent epidemic which has immense human, social and
economic costs”
Ms Laoura Lazouras, on behalf of G77, United Nations, 2006
“…a major disease representing a significant burden across
the EU”
European Parliament, 2006
“…246 million people worldwide are suffering from
diabetes…reaching 380 million by 2025”
International Diabetes Federation, 2006
“Three quarters of diabetics are type 2 diabetics and two
thirds of them have a disease that could be preventable…
The truth is we all now pay a collective price for the failure
to take shared responsibility”
United Kingdom Prime Minister Tony Blair, 2006
“If we fail to act, we will not be forgiven by the people who
live shorter and poorer lives then they deserve”
United States President Bill Clinton, 2007
Prepared by Novo Nordisk and by Dr. Antonio Nicolucci – Head of the Deparment of Clinical Pharmacology and Epidemiology, Mario Negri Sud Consortium, S. Maria Imbaro (Chieti)
“…Given the prevalence diabetes has also been showing in
developing countries, we can foresee than in 5 years there will
no longer be sufficient resources in the world to control this
serious phenomenon”
Senator Antonio Tomassini, Chair of the 12th Committee on Hygiene and Health of the Republic, Italian Changing Diabetes Barometer Forum, Aprile 2008
The challenge
of a pandemic
… in 2007, 246 million people worldwide had
diabetes, representing 6% of the population
aged 20-79. This number is expected to reach
380 million by 2025 …
Diabetes is increasing at alarming rates worldwide. The numbers of people being diagnosed with diabetes is increasing, and they are living longer, leading to rapidly rising prevalence.
The International Diabetes Federation (IDF) estimates that in 2007 246 million people worldwide had diabetes, representing 6% of the population aged 20-79. This number is expected to reach 380 million by 2025, or 7.3% of the world’s adult population.
Meanwhile a high proportion of people with diabetes remain undiagnosed or are diagnosed too late to be able to manage the disease in a way which avoids the costly complications associated with it.
The rapid increase is being fuelled by an ageing
population and by increasingly unhealthy lifestyles with poor diet and dropping levels of exercise.
The outcome of unhealthy lifestyles is increasing obesity (defined as a body mass index (BMI) in excess of 30) and this greatly increases the risk of an individual developing type 2 diabetes.
There is no cure for diabetes, despite ongoing efforts, but the burden can be effectively managed, and the risk factors can be reduced. Meeting the challenge of diabetes may not be simple but it is achievable with engagement from a wide range of parties and clear information to light the way.
Without information or action we are sleepwalking into a preventable pandemic.
The growth of diabetes,
and what’s driving it
Diabetes is increasing so severely that healthcare systems will soon be struggling
to cope. Increasing childhood obesity worldwide is to diabetes and chronic disease
what melting glaciers is to climate change; a warning signal of times to come.
Source: Hu, F.B et al 40 35 30 25 20 15 10 5 0 Relative risk
Body mass index
<23 – 25 – 30 – 35 >35
Body mass index and risk of type 2 diabetes
Growth of diabetes
in
Italy
116 110 0 150 100 50 200money in the future
Baseline treatment Enhanced treatment
100 103
178 151
First year
after change 10th yearafter change 20th yearafter change
2
1
Diabetes prevalence, diagnosed, undiagnosed, total
Diagnosed Undiagnosed 2500000 2000000 1000000 500000 1500000 3000000 Obesity in Country 1996 2006 0 2500000 1500000 2000000 1000000 500000 3000000 Diabetes prevalence Diagnosed Undiagnosed 2006 2008 2010 2012 2007 2005 191000 1766391 191000 1766391 191000 1766391 0 5 25 15 20 10 30 40 45 35 1.65 36.75 37.65 23.95 1.6 41.85 39.1 17.4
Underweight Normal Overweight Obese
116 110 0 150 100 50 200
money in the future
Baseline treatment Enhanced treatment
100 103
178 151
First year
after change 10th yearafter change 20th yearafter change
2
1
Diabetes prevalence, diagnosed, undiagnosed, total
Diagnosed Undiagnosed 2500000 2000000 1000000 500000 1500000 3000000 Obesity in Italy 1996 2006 0 2500000 1500000 2000000 1000000 500000 3000000 Diabetes prevalence Diagnosed Undiagnosed 2006 2008 2010 2012 2007 2005 191000 1766391 191000 1766391 191000 1766391 0 5 25 15 20 10 30 40 45 35 1.65 36.75 37.65 23.95 1.6 41.85 39.1 17.4
Underweight Normal Overweight Obese
116 110
0 150
100 50
Baseline treatment Enhanced treatment
100 103
178 151
First year
after change 10th yearafter change 20th yearafter change
2
1
Diabetes prevalence, diagnosed, undiagnosed, total
Diagnosed Undiagnosed 2500000 2000000 1000000 500000 1500000 3000000 Obesity in Country 1996 2006 0 2500000 1500000 2000000 1000000 500000 3000000 Diabetes prevalence Diagnosed Undiagnosed 2006 2008 2010 2012 2007 2005 191000 1766391 191000 1766391 191000 1766391 0 5 25 15 20 10 30 40 45 35 1.65 36.75 37.65 23.95 1.6 41.85 39.1 17.4
Underweight Normal Overweight Obese
In Italy, over 3.5 million people, or 6% of our population has diabetes,
but only 4.5% have been diagnosed. That means 2.6 million people have
diabetes but are receiving no treatment.
By 2010 it is estimated that there will be over 4.5 million people with
diabetes in Italy.
In Italy, 34.2% of adults are overweight, and 9.8% are obese.
According to the estimates, there are over 4.7 obese and their
number has increased by 9% in as little as 5 years.
The impact of diabetes
… people with diabetes need medical treatment
for life, and have a significantly increased risk of
suffering serious complications, including heart
attack, stroke, kidney failure, blindness and ulcers
leading to foot amputation …
What is diabetes?
Diabetes is a chronic, debilitating disease which requires life-long
treatment and predisposes to many serious, costly complications.
Heart attack Risk: Increased by 300%, and heart disease is up to 4 times as likely. Effective treatment: Leads to a reduction in heartfailure of over 50%. Stroke Risk: Up to 4 times as likely. Effective treatment: Reduces strokes by more then a third.
Diabetes
A chronic disease where blood glucose is too high, either because insulin is not produced or is insufficient.
Symptoms
Tiredness, weight loss, increased thirst, passing a lot of urine, blurred vision
Complications
Serious complications can result from elevated blood glucose, some of which are illustrated here. However these are largely preventable, and can be delayed with early diagnosis and effective treatment.
Total Kidney Failure
Risk:
3 times as likely as in the normal population. Effective treatment: Reduces the causes of kidney failure by more than a third.
Amputation
Risk:
A leading cause of non-traumatic lower-limb amputations.
Effective treatment: Reduces the number of amputations and effective eduction reduces the number of foot ulcers.
Blindness
Risk:
Major cause of adult blindness. Diabetes is a leading cause of blindness. Effective treatment: Reduces serious deterioration by more than a third.
Effective treatment
can reduce costly
diabetes complications
by up to 50%
Diabetes is a chronic disease affecting how the body is able to process glucose from sweet or starchy foods. It has two main forms, called type 1 and type 2 diabetes, people with either type need medical treatment for life, and have a significantly increased risk of suffering serious complications, including heart attack, stroke, kidney failure, blindness and ulcers leading to foot amputation.
In type 1 diabetes, the pancreas is unable to produce any insulin (insulin being a hormone enabling glucose to be used in the body’s cells to release energy). Type 1 diabetes is treated by insulin injections and by careful balance of diet (which provides glucose) and exercise (which uses it up). If the level of blood glucose falls too low, it can lead to unconsciousness. If the blood glucose level remains too high, the body uses fat reserves instead of glucose as an energy source; giving rise to the release of toxic ketones and acids, which can lead to coma and death.
In type 2 diabetes, the pancreas produces only a limited amount of insulin, and what it does produce is not working properly. Type 2 diabetes can initially be controlled by a healthy diet, weight loss and increased physical activity. But most people with type 2 diabetes will need treatment with tablets to stimulate production of more insulin, to improve the use of available insulin, or to slow the rate of glucose absorption from the digestive system. People with type 2 diabetes can (and frequently will) also need insulin treatment.
Why don’t we hear more about it?
Despite its rapidly growing prevalence, and the escalating costs of treating the disease, diabetes does not receive the urgent attention that it should. It remains seriously under-reported, partly because many people with type 2 diabetes do not realize they have it and do not seek help for what they see as minor symptoms until they have been established for years. Diabetes is also often not recorded as the cause of death, where the main cause of death may have been one of the typical diabetes complications such as heart attack, stroke or kidney failure.
What does diabetes mean to the individual? A diagnosis of diabetes means that managing the disease has to become a part of that person’s life; as yet it has no cure. The person with diabetes has to manage the balance between diet, medication and exercise on a daily basis. This presents many problems and often leads to depression, so it is important that people with diabetes have access to full and accurate information, training in the practical skills they need, and psychosocial support to help them achieve control and confidence.
Each year…
…70-80,000 people suffer heart attacks as a
result of diabetes
…About 18,000 people suffer stroke as a result of
diabetes
…Over 20,000 people experience kidney failure
as a result of diabetes
…5-6,000 people have limbs amputated as
a result of diabetes
Diabetes caused 18,000 deaths in 1 year in Italy (ISTAT Yearly Report 2002).
Our target is for people with diabetes to maintain their blood glucose level (HbA1c) below 7%.
It is estimated that 48% of people treated at the diabetes centres achieve that target (AMD Annals 2008).
Impact of diabetes
in Italy
The costs of diabetes
… Treatment and strategies for prevention of
diabetes worldwide in 2007 are estimated at
US$ 232 billion; rising to US$ 302.5 billion by
2025 … Diabetes also results in indirect costs
to the economy and the individual which can
far exceed the costs of medical care …
The costs of diabetes are very significant to both the individual and to the wider economy, and they are growing. Diabetes places an increasing burden on both, in direct costs of providing healthcare, and also in the indirect costs to society of lost productivity and social care, and financial losses to the individual.
In many countries healthcare spending has risen faster than the growth in GDP per head of the population, and is taking an increasing share of the budgets of governments, employers and individuals. Treatment and strategies for prevention of diabetes worldwide in 2007 are estimated at US$ 232 billion; rising to US$ 302.5 billion by 2025. Because of the growth in prevalence of non-communicable diseases in relation to infectious diseases, the increasing call on governments’ healthcare spending may cause critical competition for finance within the healthcare budget and between that and other public services.
In countries with developed economies, up to three-quarters of the spending on diabetes care goes on treatment of its medical complications (like stroke and kidney failure) in hospitals. But in the developing world costs are distorted by the fact that many people cannot afford treatment and care and therefore do not get it, and that a very large part of economic activity takes place by bartering or unregistered trading. By preventing people with diabetes and their carers from working, the disease hits at the very core of their ability to make a living.
Diabetes also results in indirect costs to the economy and the individual which can far exceed the costs of medical care. While people with diabetes are still able to work, it can however impact their ability to function to their full ability. It may involve them taking time off work through illness or because of hospital treatments,
and eventually lead to early retirement through disability, and premature death. Those people, with their training and experience, are lost to the workforce. The cost of diabetes to national productivity is great, and proportionately greater for less well-developed economies.
At the personal level, people with diabetes suffer lost earnings if they have to give up work. Their care may be provided by family members, who will also lose earnings. Most industrialised countries have organised medical insurance schemes and/or government-supported healthcare services, so financial strain is not added to the physical suffering caused by diabetes, but in many developing countries, people with diabetes are obliged to pay for their own medical treatment costs. For example, up to 25% of household income in India is required to cover these costs, and 30% of poor households in China attribute their poverty to healthcare costs. Even in the USA as many as three million people with diabetes may have insufficient cover to provide reasonable healthcare, or none at all.
How cost savings are possible
In recent years much evidence has shown that
enhanced treatment improves the long-term prospects of the person with diabetes, as it can delay the onset of complications. More effective treatment at an earlier stage will marginally increase the early costs, but will reduce costs in the longer term by delaying or preventing the hospital treatment needed for a wide range of complications. In addition, intensive treatment with several anti-diabetic drugs has been shown to reduce diabetes-related mortality by 50% over 13 years, and begins to save healthcare costs after as little as four years.
Source: CORE/IMS based on newly diagnosed UKPDS cohort at age 52
Note: Earlier detection & treatment simulated as a patient population with no complications at diagnosis. Better treatment simulated as patient population treated to target of HbA1c = 7.0
52
52
52
65-68
69-71
71
62-64
68-70
70
60-62
66-68 68
Baseline
(HbA1c
= 9.1%)
Age at
diagnosis
complications
Minor
complications
Minor
Minor
complications
Major
complications
Major
complications
Better
treatment
(HbA1c
= 7.0%)
Earlier
detection
& better
treatment
25-35%*
25-40%*
25-60%*
25-65%*
Earlier detection and better treatment extends and improve lives
* Average risk reducton
The direct and indirect
costs of diabetes
As well as the enormous burden of suffering on the people who have it,
diabetes places an enormous financial burden on them, their families, and on
the economy. Evidence shows that diagnosing diabetes earlier and giving proper
care actually reduces healthcare costs, because it reduces the chance or delays
the development of costly complications.
Computer simulation models can throw further light onto this question, allowing greater understanding of how best to influence treatment decisions. One simulation takes as its starting point the UKPDS (UK Prospective Diabetes Study 1998), which showed that there was a significant relationship between better control of blood glucose and reduced or delayed development of diabetes-related complications. The simulation used data from UK patients and the CORE Diabetes Model (CDM), an extensively validated health economics model developed to predict outcomes in patients with type 1 or type 2 diabetes. It has enabled calculations to be made on how the course of diabetes is improved by provision of effective care.
The simulation contrasts two hypothetical cases: two men, ‘John’ and ‘Peter’, both diagnosed with diabetes when aged 52. John, diagnosed almost by accident because of another medical investigation, is already experiencing some symptoms at the time of diagnosis. His treatment for diabetes is managed through occasional visits to the doctor, and he has an HbA1c level (the measure of glucose in the blood over a period of a few weeks) of 9.0%. On the basis of existing evidence on what usually happens to people with diabetes, John can expect 8-10 years before he suffers complications (at age 60-62), and his expected life span is 16 years from diagnosis (at age 68).
In contrast, Peter’s diabetes is diagnosed before any symptoms have developed, through routine GP monitoring. His treatment and further monitoring are given through regular three-monthly consultations, and his HbA1c is 7.0%. Although diagnosed at the same age as John, he can expect 13 years with a good quality of life before experiencing any complications (at age 65-68), and has a life expectancy of 19 years (to age 69-71).
These cases are not unusual – out of all people with diabetes, about a third have an experience like John, a third like Peter and the remainder somewhere between the two. The risk of complications is up to 70% lower and at a later stage for Peter, because earlier detection and better treatment lead to a better and longer life. Our target must be to achieve this level of care for more people with diabetes throughout the world.
Early investment will save money in the future As well as the effects on the individual person with diabetes, the costs of their treatment are a real problem for providers of healthcare services. More effective monitoring and treatment, as received by Peter, will cost more initially but give tighter control. As the largest part of the costs generated by diabetes is that of treating complications, Peter’s costs overall will actually be lower.
Enhanced treatment like that offered to Peter will cost slightly more at first due to medication and its administration. But because he will remain well for longer, he will not be troubled with the complications of diabetes so soon, or to such an extent as he would with less effective treatment. Applying the enhanced treatment scenario to the population at large, where the effects of the change take time to filter through, leads to a break-even point after about 6-8 years, and after that managing diabetes effectively gives an overall reduction in the costs of care.
There is therefore a sound economic basis for investing in managing diabetes well. In other words, earlier and better treatment reduces costs.
Return on investment in enhanced treatment (UK situation simulation)
200 150 100 50 0 First year
after change after change10th year after change20th year 100
Baseline treatment Enhanced treatment 103 116 110 178 151 £3,450m £4,000m £6,150m £3,550m £3,800m £5,200m
Source: IMS Health: Medical Ambition II - Supplement: Extension to newly diagnosed patients, Basel Switzerland, 2007 Note: Earlier detection & treatment simulated as a patient population with no
complications at diagnosis. Better treatment simulated as patient population treated to target of HbA1c = 7.0
Source: CORE/IMS based on newly diagnosed UKPDS cohort at age 52 100 50 0 % Baseline (HbA1c=9.1) “John” “Peter”
Earlier detection and better treatment
(HbA1c=7.0) Earlier detection and better treatment reduces total healthcare costs
Lifetime treatment costs
Complication costs Management cost
Implementation of anti diabetic medication Anti diabetic medication
Diabetes costs 5 billion euro per year, but the majority of this is spent on
treating the complications of the disease, many of which can be prevented.
Diabetes costs a further 235 million euro per year in terms of impact on
individuals and the economy.
The total cost of treating diabetes is estimated to increase by as much as
50% in the next few years (estimates referring to the U.S.A.).
Costs of diabetes
Healthcare spending by diseaseTotal Cancer Heart disease Diabetes 0 50 100 150 Hospitalisation Outpatient care
Antidiabetic drugs (OAD + insulin) Other drugs
Direct spending on diabetes
100 75 50 25 0 55% 7% 18% 20%
What can be done?
…With appropriate interventions the rapid rise of
type 2 diabetes can be stopped, and people with
diabetes can be helped to live with, rather than
suffer from, their disease…
There is strong evidence that preventative measures have substantial positive effects throughout the “type 2 diabetes journey”. A range of interventions is needed. Stopping diabetes – Primary prevention involves encouraging healthy lifestyle, with a good, balanced diet and moderate exercise, such that any risk of developing diabetes is minimised and diagnosis of type 2 diabetes is not reached. It’s about combating obesity through tackling sedentary western lifestyles.
Stopping costly diabetes complications – Secondary prevention involves identifying people with diabetes as early as possible and providing education on healthy lifestyle, and enhanced treatment support in order to prevent the development of complications. It needs close monitoring of the progress, and particularly of key indicators of the onset of complications, like retinopathy screening.
Stopping diabetes – Primary prevention
Securing the necessary engagement for the complex web of support required to encourage members of the population at large to live more healthily may be politically and practically challenging, but it can be done and it can be effective.
While measures aimed at the whole population may seem too large a challenge, individuals with risk factors or with pre-diabetes can be identified and intervention can prevent or delay the onset of diabetes.
Recent studies (Waugh M et al; Colagiuri S, Walker AE; Gillies C L et al) have concluded that screening for diabetes and pre-diabetes is cost-effective in the part of the population aged over 40, and early intervention as soon as pre-diabetes is detected produces significant savings in healthcare costs in the long term.
Pre-diabetes is defined by the WHO as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) and is a condition in which your blood glucose (blood sugar) levels are higher than normal but not high enough for a diagnosis of diabetes. Having pre-diabetes puts you at higher risk of developing type 2 diabetes. If you have pre-diabetes, you are also at increased risk of developing cardiovascular disease.
Prevention: What’s the evidence?
The Diabetes Prevention Program (DPP) study (2002), conducted at 27 sites through the US and involving 3,000 overweight or heavier patients, showed that people with pre-diabetes can prevent the development of type 2 diabetes through lifestyle modification - by making changes in their diet and increasing their level of physical activity – or medication. They may even be able to return their blood glucose levels to the normal range.
Just 30 minutes a day of moderate physical activity, coupled with a 5-10% reduction in body weight, produced a 58% reduction in diabetes incidence while those on metformin (an oral diabetes treatment widely used soon after diagnosis) reduced diabetes incidence by 31% compared with placebo. Those participants aged 60 years and older reduced their risk by 71%. The Da Qing study in China (1997), involving people with diabetes with a mean age of 45, showed that diet intervention alone was associated with a 31% reduction, while the exercise intervention alone showed a 46% reduction in the risk of developing type 2 diabetes during a 6-year follow-up period.
The Finnish diabetes prevention study (2003) involved over 500 overweight, middle-aged men at high risk of developing diabetes. After four years, those given an improved diet and increased physical activity showed a 58% reduction in diabetes incidence. In cases where 80% of diet, exercise and weight loss goals were met patients did not develop type 2 diabetes.
The Indian Diabetes Prevention Programme (IDPP, 2006) also examined whether the progression to diabetes could be influenced by interventions in lifestyle and with metformin treatment. The relative risk of developing diabetes was reduced by 28.5% with lifestyle modifications and by 26.4% with metformin.
Although certain groups are at higher risks of developing diabetes, these studies showed a significant reduction of diabetes incidence through lifestyle modification and medication, regardless of the ethnic background.
Primary prevention is possible
The diagram represents the full cycle of type 2 diabetes, from the population at large, where lifestyle interventions can be very effective at managing the incidence of risk factors, through the stage of pre-diabetes (IGT/IFG) to diagnosis and on to treatment and the risk of complications.
Prevention works
Up to 90% of cases of type 2 diabetes can be prevented and much of the
suffering associated with the complications of diabetes can also be prevented.
Lifestyle
Medical Intervention
Risk Factors IGT/IFG POPULA TION Baseline treatment Enhanced treatment 52 52 60-62 69-71 66-68 65-68 68 71 Age at diagnosis Age at diagnosis Major complications Minor complications Minor complications Major complicationsStopping costly diabetes complications – Secondary prevention
The UK Prospective Diabetes Study (UKPDS, 1998) showed conclusively that effective treatment of diabetes can greatly reduce diabetes complications such as heart attack (more than 50%), stroke (by more than a third) and serious deterioration of vision (by up to 33%). Effective treatment involves close monitoring and control of blood glucose levels, blood pressure and lipids (fats, such as cholesterol). The UKPDS established that the effect of managing more than one factor was greater than the combined effect of managing each factor individually.
However, diabetes is a progressive disease. Even with effective management the disease progresses from year to year and treatment regimes need to be altered to maintain good control.
While work to find a cure for diabetes continues, it is possible to reduce the effects of the disease greatly, which also reduces the cost, as shown above, and with patient and doctor working closely together they can together change diabetes, ensuring the person lives with, rather than suffers from the disease.
Risk of heart attack in relation to blood glucose and blood pressure
50 40 30 20 10 0 8 150 7-8 140-150 6-7 130-140 <6 <130 Systolic blood pr essure
Blood glucose (HbA1c)
Risk of heart attack
Source: Stratton et al. (2006)
Prevention – an internationally agreed priority The United Nations and the European Union have both recognised the threat that growing diabetes prevalence poses as well as put the emphasis on preventative initiatives. UN Resolution 61/225 of 20 December 2006 “encourages Member States to develop national policies for the prevention, treatment and care of diabetes in line with the sustainable development of their health care systems as outlined in internationally agreed development goals including the Millennium Development Goals.”
The European Parliament, in a written declaration of 2006 said that the Commission and Council should “prioritise diabetes in the EU’s new health strategy as a major disease representing a significant burden across the EU” and a Council conclusion of 2006 said that “diabetes is one of the major causes of death and premature death…it is possible to prevent or delay the onset of type 2 diabetes…[and] that urgent targeted action on diabetes and the underlying health determinants is needed to address the growing
incidence and prevalence of disease as well as the rise in the direct and indirect costs thereof.”
In the face of preventable incidence, and preventable suffering, changing diabetes must be a priority.
What needs to change?
Measure
- Collect information on as local
a level as possible
Share
- Publish this information and identify
the best practices
Improve
- Learn from the differences, exchange
the best practices and implement them to
improve outcomes for people with diabetes
Prevention works. This means that the growth in type 2 diabetes incidence can be slowed and the impact of the disease on individuals, healthcare systems and the economy can be reduced. Spreading best practice regarding from primary prevention interventions and treatment regimes, requires measurement, sharing of this information, and improvement based on adoption of best practices.
Launched in November 2007 the Changing Diabetes Barometer initiative aims to improve lives of people with diabetes and reduce costs caused by this progressive chronic disease.
The initiative seeks to achieve these aims by inspiring the collection and sharing of important information on the size of the burden of diabetes, and the effectiveness of interventions to combat it. At its centre is a message to all involved in meeting the challenge of diabetes, a call to ‘measure, share and improve’.
As illustrated elsewhere in this report, appropriate responses to the growing prevalence of diabetes are known, but ensuring universally high standards remains a challenge. Measuring and sharing will lead to healthy competition between healthcare professionals, between health systems and even between people with diabetes themselves, playing as they do a central role in effective diabetes care, which will in turn lead to improvements. The initiative argues that data must be collected to show the impact of varying efforts and approaches to reduce diabetes incidence, diagnose the disease early, and treat it effectively, reducing the incidence of diabetes related complications and early deaths. For a situation to be managed, it must be measured.
At an international level the Changing Diabetes
Barometer initiative collects success stories and monitors progress, inspiring the healthy competition which will lead to improved patient outcomes. At a national level the Changing Diabetes Barometer facilitates informed dialogue between stakeholders to bring about the conditions where such an exchange of best practice, based on clear evidence, can occur.
Does collecting and sharing information make a difference? Examples in Sweden Israel and Italy show that it does.
Measure, share, improve – Example cases Diabetes care and the extent to which it is recorded both vary significantly in different parts of the world. But early attempts in some countries to measure and record it are already showing links to significant improvements in diabetes care. The initiatives of three countries show what can be achieved through systematic recording and analysis of data. These examples of best practice are a source of insight on the different ways the problem can be tackled, the attitudes of participants and other interested parties, the difficulties encountered and the various solutions used to overcome them.
Sweden
The Swedish National Diabetes Register (NDR) was started in 1996 to provide the evidence for continuous quality assessment of diabetes care. Data on 17 aspects of health, lifestyle, biochemical measurements and complications are registered annually and now cover over 40% of the total number of people with diabetes in Sweden.
Data covering 1996-2005 gives a clear picture of improvement. For example, the average HbA1c of
people with type 2 diabetes fell from 7.4% in 1996 to 6.9% in 2005. Similar reductions were shown in average blood pressure levels. Such a reduction in HbA1c would, according to the results of the UKPDS lead to a reduction of 4% in any complication of diabetes and of 8% in microvascular complications. . Israel
In Israel, diabetes treatment is provided by four health maintenance organisations (HMOs), of which the largest is Clalit Health Services. Clalit has operated the Diabetes in the Community Programme since 1995. When it began in 1995, 70,000 people within the Clalit Health Services were known to have diabetes. In 1996 a diabetes register was introduced in each of Clalit’s 1,300 clinics; these were computerised by 2000 and all primary care physicians were invited to contribute data on their diabetes patients. The results for each clinic are compared regularly with the others. At the same time Clalit started a multidisciplinary programme of education and training for its medical staff, to show doctors and nurses how to back medical treatment with guidance for patients on lifestyle, diet and exercise. In the 12 years since the Clalit programme began, many more people have been diagnosed with diabetes in Israel. Healthcare professionals are now competing to produce the best outcomes and are seeking more frequent publication. The proportion of patients with HbA1c over 9% has fallen progressively from 40% in 1995 to 14% in 2007. Meanwhile, Clalit calculates that improved treatment is leading to reduced overall healthcare costs per person with diabetes, and they estimate a payback period to recover initial investment in more effective care of 6-8 years.
1 1 1 Measure Share Improve
The changing diabetes
barometer initiative
Launched in November 2007 the Changing Diabetes Barometer initiative aims to improve lives of people with diabetes and reduce costs caused by this progressive chronic disease.
The initiative seeks to achieve these aims by inspiring the collection and sharing of important information on the size of the burden of diabetes, and the effectiveness of interventions to combat it. At its centre is a message to all involved in meeting the challenge of diabetes, a call to ‘measure, share and improve’.
As illustrated elsewhere in this report, appropriate responses to the growing prevalence of diabetes are known, but ensuring universally high standards remains a challenge. Measuring and sharing will lead to healthy competition between healthcare professionals, between health systems and even between people with diabetes themselves, playing as they do a central role in effective diabetes care, which will in turn lead to improvements. The initiative argues that data must be collected to show the impact of varying efforts and approaches to reduce diabetes incidence, diagnose the disease early, and treat it effectively, reducing the incidence of diabetes related complications and early deaths. For a situation to be managed, it must be measured.
At an international level the Changing Diabetes
Barometer initiative collects success stories and monitors progress, inspiring the healthy competition which will lead to improved patient outcomes. At a national level the Changing Diabetes Barometer facilitates informed dialogue between stakeholders to bring about the conditions where such an exchange of best practice, based on clear evidence, can occur.
Does collecting and sharing information make a difference? Examples in Sweden Israel and Italy show that it does.
In April 2008, Rome, Novo Nordisk organized the First Changing Diabetes Barometer
Forum to discuss the current state of diabetes in Italy and how savings, both in terms
of personal suffering and financial impact, might be possible.
The meeting was attended by:
The presidents, board members and regional representatives of the AMD (Association of Diabetes Specialists),
SID (Italian Diabetes Society), SIEDP (Italian Society for Paediatric Endocrinology and Diabetology), the presidents
of the national associations of people with diabetes, chairs and members of the parliamentary committees on health,
representatives of regional authorities, experts and journalists They concluded:
• Adequacy of national strategy for diabetes treatment and prevention
• Efforts to manage rising obesity and prevent type 2 diabetes • Early identification and screening plans
• Progress against targets for the treatment of diabetes
• Adequacy of national data and systems to spread best practice "… It is on us, now, trying to bring the results of our daily work closer to the diabetes care standards.
To this end, we need to consistently benchmark ourselves, and the Diabetes Barometer Forum represents an
opportunity to compare make take future commitments." Adolfo Arcangeli, President of Diabetes Italia and the AMD (Association of Diabetes Specialists)
What needs to change
in Italy
Bibliography:
Annali AMD 2006,2007,2008
– ISTAT. Condizioni di salute, fattori di rischio e ricorso ai servizi sanitari. Anno 2005
– ISTAT. Fattori di rischio e tutela della salute. Indagine Multiscopo sulle famiglie “Condizioni di salute e ricorso ai servizi sanitari” Anni 1999-2000
– ISTAT. Cause di morte. Anno 2002. – IDF Atlas. Terza edizione; 2006.
– G. Vespasiani, A. Nicolucci, C. Giorda. Epidemiologia del diabete. Annali della Sanità Pubblica 2005.
– Bonora E, Kiechl S, Willeit J, Oberhollenzer F, Egger G, Meigs JB, Bonadonna RC, Muggeo M; Bruneck study. Population-based incidence rates and risk factors for type 2 diabetes in white individuals: the Bruneck study. Diabetes. 2004;53:1782-9. – Bruno G, Biggeri A, Merletti F, Bargero G, Ferrero S, Pagano G,
Perin PC. Low incidence of end-stage renal disease and chronic renal failure in type 2 diabetes: a 10-year prospective study. Diabetes Care. 2003;26:2353-8.
– Avogaro A, Giorda C, Maggini M, Mannucci E, Raschetti R, Lombardo F, Spila-Alegiani S, Turco S, Velussi M, Ferrannini E; Diabetes and Informatics Study Group, Association of Clinical Diabetologists, Istituto Superiore di Sanità. Incidence of coronary heart disease in type 2 diabetic men and women: impact of microvascular complications, treatment, and geographic location. Diabetes Care. 2007;30:1241-7.
– Giorda CB, Avogaro A, Maggini M, Lombardo F, Mannucci E, Turco S, Alegiani SS, Raschetti R, Velussi M, Ferrannini E; The DAI Study Group. Incidence and risk factors for stroke in type 2 diabetic patients: the DAI study. Stroke. 2007 ;38:1154-60.
– Lucioni C, Garancini MP, Massi-Benedetti M, Mazzi S, Serra G; CODE-2 Italian Advisory Board. The costs of type 2 diabetes mellitus in Italy: a CODE-2 sub-study. Treat Endocrinol. 2003;2:121-33.
– Cimino A, De Bigontina G, Giorda C, Meloncelli I, Nicolucci A, Pellegrini F, Rossi MC, Vespasiani G. Annali AMD 2008.
