Chronic Disease Epidemic – the Figures for Diabetes. Pieber T. eHealth week 2010 (Barcelona: CCIB Convention Centre; 2010)

1. Chronic Disease Epidemic –
The Figures for Diabetes
Thomas R. Pieber
Medical University of Graz
Austria

2. Conflict of Interest
• The invited speaker has or had research co-
operations with companies producing glucose
lowering drugs or other diabetes related
products.
• Furthermore, the invited speaker was or is
consultant or speaker at meetings for
companies producing glucose lowering drugs,
in many cases a honorarium as or is paid.

3. Diabetes mellitus – a global burden
• Defined by elevated blood glucose
• Fasting: ≥7.0 mmol/l (126 mg/dl)
• Postprandial or after glucose load:
≥11.1 mmol/l (200mg/dl)
• Typical, but non-specific symptoms including
thirst, increased urine volume, exhaustion,
impaired wound healing, itching
• Type 1 diabetes (~10%) – type 2 diabetes (~90%)
• Chronic disease without cure
• Increasing incidences
• Burden of late complications

4. Diabetes mellitus type 1
• Autoimmune disease
leading to absolute
insulin deficiency
• Genetic factors
• Environment
• Increasing incidence,
doubling of new cases
in 2020-2025
• Shift to younger children Harjutsalo, 2008
• Shift to ‘low-risk’ groups
Patterson, 2009

5. Diabetes mellitus type 2
• Impaired insulin action
and insulin secretion
• Genetic factors
• Age
• Obesity
• Sedentary life style
• EU: prevalence of 6-10%
• Increase in all age groups (including children)
• Epidemics of obesity leads to epidemics of type 2
diabetes (380 Mio in 2025)

6. Diabetes mellitus – microvascular
complications
• Caused by hyperglycaemia
• Diabetic nephropathy
• Diabetes is the leading cause for
kidney replacement therapy
• DNP can be prevented
• Progression of DNP can be halted
• Diabetic retinopathy
• Diabetes is the leading cause
for blindness in adults
• DRP can be prevented
• Progression of DRP can be halted

7. Diabetes mellitus – macrovascular
complications
• Caused by diabetes-associated risk factors
(hypertension, dyslipidaemia, hyperglycaemia,
microvascular complications)
• Diabetes is associated with
2-4x risk of myocardial
infarction, heart failure,
and stroke
• Increased mortality
• Prevention and
adequate treatment

8. Diabetes mellitus – diabetic foot
syndrome
• Caused by diabetic neuropathy, vascular disease
and inadequate medical management
• Diabetes is the leading
cause for amputations
of the lower limb (10-20x)
• Increased mortality
• DFS can be prevented
• Progression of DFS
can be halted

9. “The Diabetes Paradoxon”
• Diabetes is a complex chronic disease associated
with devastating late complications
• Dramatic increase in prevalence
• Diabetes associated late complications could be
prevented or reduced
• Diabetes is an expensive disease
• Health care systems fail to provide adequate care
for citizens with diabetes

10. “The Diabetes Paradoxon”
• Health care system
• Interfaces between caregivers not defined
• Roles of caregivers not defined, referrals
are not organised
• Conflict of interest between different providers
• Quality of care
• Missing or insufficient documentation
• Inadequate knowledge or implementation of evidence
• Diabetic patient
• Lack of patient education
• Lack of empowerment

11. Disease Management Programme
• Approach to patient care that emphasizes
coordinated, comprehensive care along the
continuum of disease and across health care
delivery systems
• Views patients as entities experiencing the
clinical course of a disease
Ellrodt et al., JAMA 1997;278(20):1687-1692
Hunter/Fairfield, BMJ 1997;315:50-53

12. What’s inside a DMP? (I)
Quality Improvement Strategies
DMAA recommendations for Disease Management
• Population identification process
• Evidence-based practice guidelines
• Collaborative practice model to include physician and support-
service providers
• Risk identification and matching of interventions with need
• Patient self-management education
• Process and outcomes measurement,
evaluation and management
• Routine reporting/feedback loop
• Appropriate use of information technology
Disease Management Association of America (DMAA), 2002

13. What’s inside a DMP? (II)
Quality Improvement Strategies
Classification of Strategies according to Cochrane
EPOC (Effective Practice and Organization of Care) Group
• Audit and Feedback • Case Management
• Team Changes • Electronic Patient Registry
• Clinician Reminders • Clinician Education
• Facilitated Relay of Clinical Information to Clinicians
• Patient Education • Promotion of Self-Management
• Patient Reminder Systems
• Continuous Quality Improvement
Cochrane EPOC Group, 2001

14. Disease Management Programme -
Components
Population
Identification
Patient Evidence Based
Empowerment Care Pathways
Collaborative
practice model
Clinician Education Reporting &
and Training Feedback loop
Evaluation
Process Organization, Documentation, Communication
Quality Management
Information Systems

15. Evidence Based Clinical Care
Pathways and Education Initiative
15

16. Disease Management Programme –
The Evidence
The Cochrane EPOC Group – Effect on HbA1c
Shojania, 2006

17. Chronic Disease Epidemic – the
Figures for Diabetes
… care along the continuum of disease …
• Increasing prevalence for type 1 and type 2
diabetes
• Doubling in the next 10 – 15 years
• Pathophysiology only partly understood
• Substantial impact on health care systems in the
world
• Prevention programmes are urgently needed

18. Diabetes Prevention Programme
• Identification of genetic and environmental factors
leading to diabetes
• Identification of pathophysiological pathways
• Identification of effective prevention measures in
randomized controlled trials
• Identification of measures for population wide
implementation
• Evaluation and cost effectiveness

19. Conclusions
• Diabetes is a complex chronic disease with
devastating late complications
• Increasing prevalence (type 1 and type 2
diabetes)
• Late complications can be prevented or reduced
• Diabetes is an expensive disease
• Disease Management Programmes may help to
overcome major deficits in care
• Diabetes prevention is of major importance for
European health care systems