Hospitalization and re-hospitalization of people with and without diabetes in La Plata, Argentina: comparison of their clinical characteristics and costs

Effects of Guided Reflection on Diabetes Self-Care: A Randomized Controlled Trial

The purpose of this study was to evaluate the effects of guided reflection on self-care behaviors, confidence scores, and diabetes knowledge among adults with diabetes. A randomized controlled trial with a pre/posttest design was used to generate data from a convenience sample of 62 adults with diabetes recruited from a single site. After viewing a 30-minute video on how to manage diabetes, participants were randomized to a control group (CG) (usual care) or an intervention group (IG). The IG further engaged in a reflection educational session. For 8 weeks, the IG isolated diabetes-related events weekly, critically analyzed them using Gibbs's reflective questions, and recorded their analysis in a journal. They also shared their perspective relative to using the journal in an audiotaped interview. Main measures included baseline and 8-week clinical outcomes (self-care maintenance, monitoring, management, and confidence scores and diabetes knowledge scores) and intervention acceptability. Compared to the CG, the IG had no statistically significant difference in self-care measures over time, although scores trended in the anticipated direction. Importantly, both groups had statistically significant improvement in self-care scores. Furthermore, there was statistically significant improvement in diabetes knowledge among IG participants. Informatively, IG critically analyzed 147 diabetes-related events concentrating on blood glucose, diet, exercise, monitoring, medication, sleep pattern, and health care visits. Participants found the guided reflection activity highly acceptable. Combined educational and reflection interventions are effective approaches for improving self-care outcomes and diabetes knowledge among adults with diabetes. Research concentrating on purposeful patient reflection is warranted in a larger sample paying careful attention to study limitations.

Diabetes in South and Central America: an update

The estimated population of the South and Central America (SACA) Region is 467.6 million and 64% is in the age range of 20-79 years but the population pyramid and age distribution are changing. The average prevalence of diabetes in the Region is 8.0% and is expected to reach 9.8% by the year 2035. Prevalence is much lower in rural settings than in urban and the differences attributed to lifestyle changes may be a target for intervention. The indigenous population is a particularly vulnerable group needing special attention. On average, 24% of the adult cases with diabetes are undiagnosed but in some countries this is still as high as 50%. Health expenditure due to diabetes in the Region is around 9% of the global total. Inadequate glycemic control, defined as HbA1c >7%, is a strong predictor of chronic complications which increase resource use in the Region and less than half of the patients enrolled in diabetes care programmes are at target. Fifty percent or more of the adult population is overweight/obese and around one third of the adult population has metabolic syndrome using regional cutoffs for waist circumference. The number of people with IGT is almost equal to those with diabetes presenting an additional challenge for prevention. Children with type 1 diabetes represent only 0.2% of the total population with diabetes but the incidence may be increasing. In many places they have limited access to insulin, and even when available, it is not used appropriately. The available epidemiological data provide the background to act in developing national diabetes programmes which integrate diabetes care with cardiovascular prevention and promote diabetes prevention as well.

Registry of people with diabetes in three Latin American countries: a suitable approach to evaluate the quality of health care provided to people with type 2 diabetes

AIMS

To implement a patient registry and collect data related to the care provided to people with type 2 diabetes in six specialized centers of three Latin American countries, measure the quality of such care using a standardized form (QUALIDIAB) that collects information on different quality of care indicators, and analyze the potential of collecting this information for improving quality of care and conducting clinical research.

METHODS

We collected data on clinical, metabolic and therapeutic indicators, micro- and macrovascular complications, rate of use of diagnostic and therapeutic elements and hospitalization of patients with type 2 diabetes in six diabetes centers, four in Argentina and one each in Colombia and Peru.

RESULTS

We analyzed 1157 records from patients with type 2 diabetes (Argentina, 668; Colombia, 220; Peru, 269); 39 records were discarded because of data entry errors or inconsistencies. The data demonstrated frequency performance deficiencies in several procedures, including foot and ocular fundus examination and various cardiovascular screening tests. In contrast, HbA1c and cardiovascular risk factor assessments were performed with a greater frequency than recommended by international guidelines. Management of insulin therapy was sub-optimal, and deficiencies were also noted among diabetes education indicators.

CONCLUSIONS

Patient registry was successfully implemented in these clinics following an interactive educational program. The data obtained provide useful information as to deficiencies in care and may be used to guide quality of care improvement efforts.

Diabetes in Argentina: cost and management of diabetes and its complications and challenges for health policy

Background

Diabetes is an expensive disease in Argentina as well as worldwide, and its prevalence is continuously rising affecting the quality of life of people with the disease and their life expectancy. It also imposes a heavy burden to the national health care budget and on the economy in the form of productivity losses.

Aims

To review and discuss a) the reported evidence on diabetes prevalence, the degree of control, the cost of care and outcomes, b) available strategies to decrease the health and economic disease burden, and c) how the disease fits in the Argentinian health care system and policy. Finally, to propose evidence-based policy options to reduce the burden of diabetes, both from an epidemiological as well as an economic perspective, on the Argentinian society. The evidence presented is expected to help the local authorities to develop and implement effective diabetes care programmes.

Methodology

A comprehensive literature review was performed using databases such as MEDLINE, EMBASE and LILACS (Latin American and Caribbean Health Sciences). Literature published from 1980 to 2011 was included. This information was complemented with grey literature, including data from national and provincial official sources, personal communications and contacts with health authorities and diabetes experts in Argentina.

Results

Overall diabetes prevalence increased from 8.4% in 2005 to 9.6% 2009 at national level. In 2009, diabetes was the seventh leading cause of death with a mortality rate of 19.2 per 100,000 inhabitants, and it accounted for 1,328,802 DALYs lost in the adult population, mainly affecting women aged over fifty. The per capita hospitalisation cost for people with diabetes was significantly higher than for people without the disease, US$ 1,628 vs. US$ 833 in 2004. Evidence shows that implementation of combined educative interventions improved quality of care and outcomes, decreased treatment costs and optimised the use of economic resources.

Conclusions

Based on the evidence reviewed, we believe that the implementation of structured health care programmes including diabetes education at every level, could improve quality of care as well as its clinical, metabolic and economic outcomes. If implemented across the country, these programmes could decrease the disease burden and optimise the use of human and economic resources.

Diabetes inpatients: a case of lose, lose, lose. Is it time to use a 'diabetes-attributable hospitalization cost' to assess the impact of diabetes?

AIMS

The UK National Health Service in England pays for inpatients using a formula ('tariff'). The appropriateness of the tariff for people with diabetes is unknown. We have compared the tariff paid and costs for inpatients with/without diabetes and tested the concept of a 'diabetes-attributable hospitalization cost'.

METHODS

This was a cross-sectional, retrospective 12-month audit in a single teaching hospital assessing mortality, bed days per annum and 'diabetes-attributable hospitalization cost' (i.e. the proportion of costs for all patients with diabetes in excess of that paid for comparable patients without diabetes).

RESULTS

There were 64 829 inpatient admissions, with 4864 of those coded as having diabetes; 12.9% was estimated to be the number of patients having diabetes but not coded. People with diabetes occupied 13.9% of all bed days and were 18.1% (1.3-37.8%) more likely to die (age adjusted). The mean bed days per annum were greatest among those with (vs. without) diabetes (men 10.9 ± 17.0 vs. 6.3 ± 12.8; women 11.4 ± 19.4 vs. 5.9 ± 11.6; P < 0.001). The greatest excess admission rates were among those aged 25-64 years. The annual mean tariff was greater for those with diabetes (5380 ± 8740) than those without diabetes (3706 ± 6221) (P < 0.001). The overall cost was even higher among those with diabetes: 5835 ± 11 246 vs. 3567 ± 7238 (P < 0.001). The diabetes-attributable hospitalization cost was 46.5% (9 125 085). An HbA(1c) > 10.0% (> 86 mmol/mol) was associated with excess hospitalization.

CONCLUSIONS

Those with diabetes cost more and are more likely to die when inpatients. The tariff paid for diabetes is high, but in this centre less than the actual costs. Approaches known to reduce hospitalization are urgently required.

Resource use associated with type 2 diabetes in Asia, Latin America, the Middle East and Africa: results from the International Diabetes Management Practices Study (IDMPS)

AIMS

To estimate diabetes-related resource use and investigate its predictors among individuals with type 2 diabetes in 24 countries in Asia, Latin America, the Middle East and Africa.

METHODS

Cross-sectional observational data on diabetes-related resource use were collected from 15,016 individuals with type 2 diabetes within the second wave of International Diabetes Management Practices Study. Mean (SD) annual quantities were determined and predictors of diabetes-related hospitalisations, inpatient days, emergency room visits and absenteeism were investigated using negative binomial regression.

RESULTS

Patients in Asia (n = 4678), Latin America (n = 6090) and the Middle East and Africa (n = 4248) made a mean (SD) of 3.4 (6.9), 5.4 (6.7) and 2.5 (4.4) General Practitioner visits per year. The mean (SD) number of inpatient days amounted to 3.8 (18.1), 2.2 (13.9) and 2.6 (13.5) per year. Results of the regression analysis showed the major influence of diabetes-related complications and inadequate glycaemic control on resource use. The expected annual rate of hospitalisation of patients with macrovascular complications compared with those without was 4.7 times greater in Asia [incidence rate ratio (IRR) = 4.7, 95% CI: 2.8-7.8, n = 2551], 5.4 times greater in Latin America (IRR = 5.4, 95% CI: 3.0-9.8, n = 3228) and 4.4 times greater in the Middle East and Africa (IRR = 4.4, 95% CI: 2.8-6.9, n = 2630).

CONCLUSIONS

Micro- and macrovascular complications and inadequate glycaemic control are significant predictors of resource use in people with type 2 diabetes of developing countries. This knowledge confirms the health economic importance of early diagnosis of diabetes, education of patients and glycaemic control.

[Prognostic factors in patients admitted with type 2 diabetes in Internal Medicine Services: hospital mortality and readmission in one year (DICAMI study)]

INTRODUCTION

Type II diabetes mellitus (T2DM) is a prevalent Public Health Care problem that causes an increase in morbidity, mortality and number of hospital admissions as well as increased costs in care services in this population group. The clinical indicator that determine readmission and/or death are analyzed in a 12 month follow-up period.

METHODS

All T2DM patients admitted in Spanish Internal Medicine Services between two different periods (june 1-15, 2003 and november 1-15) were enrolled in a prospective cohort study. Primary endpoint were readmission and/or death in the year following the first admission.

RESULTS

Population of the study (n = 482) was distributed in 229 males (47.5%) and 253 females (52.5%). Mean age was 73.48 +/- 8.86 years. A total of 210 (43.6%) were not readmitted to the hospital and/or died in the follow-up and 272 (56.4%) were readmitted and/or died. The latter 272 patients had a significantly greater percentage of heart failure (odds ratio [OR] 1.760; 1.073-2.886), atrial fibrillation (OR 1.747; 1.010- 3.022) and previous history of systolic blood pressure (OR 0.400; 0.241-0.666). They also showed increased levels of plasma glucose (OR 1.004; 1.001-1.007), and lower concentration of plasma hemoglobin (OR 0.756; 0.677-0.845) and creatinine clearance (OR 0.985; 0.976-0.994).

CONCLUSIONS

T2DM patients who are admitted to the Internal Medicine Services in Spain are elderly patients with elevated indices of readmission and death in a short follow-up period (one year). The coexistence of heart failure, atrial fibrillation, renal dysfunction deterioration and decrease in hemoglobin levels may predict this worse outcome.

Health care utilization and costs in Saskatchewan's registered Indian population with diabetes

BACKGROUND

The prevalence of diabetes in North American is recognized to be higher in Aboriginal populations. The relative magnitude of health care utilization and expenditures between Aboriginal and non-Aboriginal populations is uncertain, however. Our objective was to compare health care utilization and per capita expenditures according to Registered Indian and diabetes status in the province of Saskatchewan.

METHODS

Administrative databases from Saskatchewan Health were used to identify registered Indians and the general population diabetes cases and two controls for each diabetes case. Health care resource utilization (physician visits, hospitalizations, day surgeries and dialysis) and costs for these individuals in the 2001 calendar year were determined. The odds of having used each resource category, adjusted for age and location of residence, was assessed according to Registered Indian and diabetes status. The average number of encounters for each resource category and per capita healthcare expenditures were also determined.

RESULTS

Registered Indian diabetes cases were younger than general population cases (45.7 +/- 14.5 versus 58.4 +/- 16.4 years, p < 0.001) and fewer were male (42.3% versus 53.2%, p < 0.001). Registered Indians were more likely to visit a physician, be hospitalized or receive dialysis than the general population, regardless of diabetes status. Diabetes increased the probability of having used all resource categories for both Registered Indians and the general population. Per capita health care expenditures for the diabetes subgroups were more than twice that of their respective controls and were 40% to 60% higher for registered Indians than the general population, regardless of diabetes status.

CONCLUSION

Relative to individuals without the disease, both registered Indians and the general population with diabetes had substantially higher health care utilization and costs. Excess hospitalization and dialysis suggested that registered Indians with and without diabetes experienced greater morbidity than the general population.

PROPAT: a study to improve the quality and reduce the cost of diabetes care

OBJECTIVE

In PROPAT we implemented an integrated approach to diabetes care designed to improve the quality and reduce the cost of care.

STUDY DESIGN AND METHODS

PROPAT was a case-control study matching patients by age and gender (diabetes:control ratio 1:2) within IOMA, a public employment-based health maintenance organization (HMO) of the Province of Buenos Aires, Argentina. Costs were evaluated using prevalence data from an HMO perspective. We currently report clinical and biochemical data and costs from the first 297 patients enrolled who completed 1 year in PROPAT, and compare them with those derived from control patients.

RESULTS

All recommended practices recorded as care provided at baseline increased significantly 1 year after implementing PROPAT, with a parallel significant improvement in several clinical and biochemical parameters, and markedly lower total annual per capita costs.

CONCLUSIONS

These results demonstrate that the implementation of a comprehensive diabetes care program can simultaneously improve quality while reducing costs.