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)

One in Seven Insulin-Treated Patients in Developing Countries Reported Poor Persistence with Insulin Therapy: Real World Evidence from the Cross-Sectional International Diabetes Management Practices Study (IDMPS)

INTRODUCTION

Although poor adherence to insulin is widely recognised, periodic discontinuation of insulin may cause more severe hyperglycaemia than poor adherence. We assessed persistence with insulin therapy in patients with type 1 (T1D) or type 2 diabetes (T2D) in developing countries and the reasons for insulin discontinuation.

METHODS

The International Diabetes Management Practices Study collected real-world data from developing countries in seven waves between 2005 and 2017. In Wave 7 (2016-2017), we asked adult patients with T1D and insulin-treated T2D to report whether they had ever discontinued insulin, the estimated duration of discontinuation and underlying reasons.

RESULTS

Among 8303 patients recruited from 24 countries by 620 physicians, 4596 were insulin-treated (T1D: 2000; T2D: 2596). In patients with T1D, 14.0% (95% CI: 12.5-15.6) reported having self-discontinued insulin for a median duration of 1.0 month (IQR: 0.5, 3.5). The respective figures in patients with T2D were 13.7% (12.4-15.1) and 2.0 months (IQR: 1.0, 6.0). The main reasons for discontinuation were impact on social life (T1D: 41.0%; T2D: 30.5%), cost of medications and test strips (T1D: 34.4%; T2D: 24.5%), fear of hypoglycaemia (T1D: 26.7%; T2D: 28.0%) and lack of support (T1D: 26.4%; T2D: 25.9%). Other factors included age < 40 years, non-university education and short disease duration (T1D: ≤ 1 year; T2D: > 1-≤ 5 years). Patients with T1D who did not perform self-monitoring of blood glucose (SMBG) or self-adjust their insulin dosage, and patients with T1D or T2D without glucose meters were less likely to persist with insulin. Nearly 50% of patients who reported poor persistence had HbA1c > 75 mmol/mol (> 9%) and > 50% of physicians recommended diabetes education programmes to improve treatment persistence.

CONCLUSION

In developing countries, poor persistence with insulin is common among insulin-treated patients, supporting calls for urgent actions to ensure easy access to insulin, tools for SMBG and education.

Screening, prevalence, treatment and control of kidney disease in patients with type 1 and type 2 diabetes in low-to-middle-income countries (2005-2017): the International Diabetes Management Practices Study (IDMPS)

AIMS/HYPOTHESIS

Diabetes is the leading cause of kidney disease worldwide. There is limited information on screening, treatment and control of kidney disease in patients with diabetes in low-to-middle-income countries (LMICs).

METHODS

The International Diabetes Management Practices Study is an ongoing, non-interventional study of clinical profiles and practices among patients receiving outpatient care mainly by internal medicine physicians and endocrinologists in LMICs. We examined screening, prevalence, treatment and control of kidney disease across seven waves (W) of data collection between 2005 and 2017.

RESULTS

Among 15,079 patients with type 1 and 66,088 patients with type 2 diabetes, screening for kidney disease increased between W2 and W3 followed by a plateau (type 1 diabetes: W2, 73.7%; W3, 84.1%; W7, 83.4%; type 2 diabetes: W2, 65.1%; W3, 82.6%; W7, 86.2%). There were also decreasing proportions of patients with microalbuminuria (type 1 diabetes: W1, 27.1%; W3, 14.7%; W7, 13.8%; type 2 diabetes: W1, 24.5%; W3, 12.6%; W7, 11.9%) and proteinuria (type 1 diabetes: W1, 14.2%; W3, 8.7%; W7, 8.2%; type 2 diabetes: W1, 15.6%; W3, 9.3%; W7, 7.6%). Fewer patients were reported as receiving dialysis for both type 1 diabetes (W2, 1.4%; W7, 0.3%) and type 2 diabetes (W2, 0.9%; W7, 0.2%) over time. While there was no change in mean HbA1c or prevalence of diagnosed hypertension (type 1 diabetes: W1, 22.7%; W7, 19.9%; type 2 diabetes: W1, 60.9%; W7, 66.2%), the use of statins had increased among patients diagnosed with dyslipidaemia (type 1 diabetes: W1, 77.7%; W7, 90.7%; type 2 diabetes: W1, 78.6%; W7, 94.7%). Angiotensin II receptor blockers (type 1 diabetes: W1, 18.0%; W7, 30.6%; type 2 diabetes: W1, 24.2%; W7, 43.6%) were increasingly used over ACE inhibitors after W1 (type 1 diabetes: W1, 65.0%; W7, 55.9%; type 2 diabetes: W1, 55.7%, W7, 41.1%) among patients diagnosed with hypertension.

CONCLUSIONS/INTERPRETATION

In LMICs, real-world data suggest improvement in screening and treatment for kidney disease in patients with type 1 and type 2 diabetes attending non-nephrology clinics. This was accompanied by decreasing proportions of patients with microalbuminuria and proteinuria, with fewer patients who reported receiving dialysis over a 12-year period.

Diabetes care quality according to facility setting: A cross-sectional analysis in six Peruvian regions

OBJECTIVE

To characterize diabetes care across healthcare facilities in six Peruvian regions.

METHODS

Cross-sectional study of patients with type 2 diabetes mellitus (T2DM), ranging from primary care facilities to hospital-based facilities, in six Peruvian regions. Data was collected by health staff trained between 2012 and 2016. We studied six diabetes care outcomes and four adequate diabetes care outcomes considering the healthcare facility as the exposure of interest. We estimated prevalence ratios (PR) and their 95% confidence intervals (95% CI) using Poisson regression with robust variance.

RESULTS

Data from 8879 patients with T2DM, mean age 59.1 years (SD ± 12.2), 53.6% males, was analyzed. Of these, 8096 (91.2%) were treated at primary care facilities. The proportions of patients who had HbA1c, LDL-c, and creatinine/microalbumin test performed increased with the setting of the healthcare facility. Overall, 39%-56% of patients had an adequate HbA1c control, being higher in hospital-based facilities with specialists in comparison to primary care facilities.

CONCLUSIONS

We observed that the higher the setting of the facility, the higher the rate of the assessed diabetes care outcomes and adequate diabetes care for four of the six targets (fasting glucose, HbA1c, LDL-c and creatinine or microalbumin) and for three of the four targets (glucose≤130 mg/dL, HbA1c ≤7%(53 mmol/mol) and LDL-c <100 mg/dL), respectively. Substantial gaps were observed at the primary care facilities, calling for the strengthening of diabetes care.

Health System Capacity and Access Barriers to Diagnosis and Treatment of CVD and Diabetes in Nepal

Background:

Universal access to essential medicines and routine diagnostics is required to combat the growing burden of cardiovascular disease (CVD) and diabetes. Evaluating health systems and various access dimensions availability, affordability, accessibility, acceptability, and quality is crucial yet rarely performed, especially in low- and middle-income countries.

Objective:

To evaluate health system capacity and barriers in accessing diagnostics and essential medicines for CVD and diabetes in Nepal.

Methods:

We conducted a WHO/HAI nationally-representative survey in 45 health-facilities (public-sector: 11; private-sector: 34) in Nepal to collect availability and price data for 21 essential medicines for treating CVD and diabetes, during MayJuly 2017. Data for 13 routine diagnostics was obtained in 12 health facilities. Medicines were considered unaffordable if the lowest paid worker spends >1 days wage to purchase a monthly supply. To evaluate accessibility, we conducted facility exit interviews among 636 CVD patients. Accessibility (e.g., private-public health facility mix, travel to hospital/pharmacy) and acceptability (i.e. Nepals adoption of WHO Essential Medicine List, and patient medication adherence) were summarized using descriptive statistics, and we conducted a systematic review of relevant literature. We did not evaluate medicine quality.

Results:

We found that mean availability of generic medicines is low (<50%) in both public and private sectors, and less than one-third medicines met WHOs availability target (80%). Mean (SD) availability of diagnostics was 73.1% (26.8%). Essential medicines appear locally unaffordable. On average, the lowest-paid worker would spend 1.03 (public-sector) and 1.26 (private-sector) days wages to purchase a monthly supply. For a person undergoing CVD secondary preventive-interventions in the private sector, the associated expenditure would be 7.511.2% of monthly household income. Exit-interviews suggest that a long/expensive commute to health-facilities and poor medicine affordability constrain access.

Conclusions:

This study highlights critical gaps in Nepals health system capacity to offer basic health services to CVD and diabetes patients, owing to low availability, poor affordability and accessibility of essential medicines and diagnostics. Research and policy initiatives are needed to ensure uninterrupted supply of affordable essential medicines and diagnostics.

Glycemic Control and Prevention of Diabetic Complications in Low- and Middle-Income Countries: An Expert Opinion

INTRODUCTION

Trends on glycemic control and diabetes complications are known for high-income countries, but comprehensive data from low- and middle-income countries (LMIC) are lacking.

METHODS

This is an expert opinion based on two retrospective studies. Here we examine the recent subset analysis of relevant data from the IDMPS Wave 7 (International Diabetes Management-Practices Study, 2015-2016) and the GOAL study conducted in multiple LMICs.

RESULTS

Wave 7 sub-analysis was performed in 6113 people with type 2 diabetes from 24 LMIC. Poorly controlled diabetes (hemogloblin A1c [HbA1c] ≥ 7%) was found in 58.6, 73.0 and 78.3% of participants with diabetes duration of < 5, 5-12 and > 12 years, respectively (in association with a high prevalence of macro- and microvascular complications). Moreover, 37.7% of participants with diabetes duration of 5-12 years were treated only with oral antihyperglycemic drugs. The GOAL study investigated the efficacy of insulin in 2704 poorly controlled participants (mean HbA1c 9.7%; diabetes duration 10.1 ± 6.7 years; 10 LMIC). A significant 2% reduction in mean HbA1c levels was observed after 12 months of treatment. Only 7.2% of participants experienced a symptomatic episode of hypoglycemia (nocturnal or severe hypoglycemia events were infrequent).

CONCLUSION

The rate of well-controlled participants (HbA1c < 7.0%) in the Wave 7 sub-analysis was lower than that observed in the USA (NHANES survey) or in European countries (GUIDANCE study), and the incidence of microvascular complications was higher. The GOAL study showed that insulin treatment improves glycemic control and reduces this gap. The Expert Panel recommends intensifying diabetes treatment as soon as possible, as well as patients' education and other preventive measures, initiatives which require modest costs compared to hospitalization and treatment of diabetes complications.

Management of adult patients with type 1 diabetes mellitus in Africa: A post-hoc cohort analysis of 12 African countries participating in the International Diabetes Management Practices Study (Wave 7)

There is a paucity of information on real world management of African adult patients with type 1 diabetes mellitus (T1DM). We aimed to describe a cohort of African adults with T1DM.The International Diabetes Management Practices Study is an observational survey conducted from 2005 to 2017. Data were collected in seven individual waves from countries in Asia, Africa, East Europe, and Latin America. Wave 7 was conducted from 2016 to 2017 and the African cohort included 12 countries. Questionnaires were administered to clinicians and patients. Analyses were mainly descriptive. Logistic regressions were performed to identify predictive factors for glycaemic control.A total of 788 patients were enrolled in the study. HbA1c values were available for 712 patients; only 16.6% had HbA1c values <7%. A total of 196 (24.9%) reported being hospitalized in the preceding year, with the most common reasons being diabetic ketoacidosis (58.1%, 93/160) and hypoglycaemia (31.1%; 52/167). Over half of the patients (55.4%) stated that the cost of test strips limited regular glycemic monitoring; a minority of patients (15%, 120/788) received structured diabetes education. Predictors of HbA1c <7% included patients receiving diabetes education (odds ratio [OR] [95% confidence interval, CI] = 2.707 [1.157-6.335] P = .022), following a healthy diet and exercise plan (OR [95% CI] = 2.253 [1.206-4.209], P < .001) and self-managing (monitoring glucose levels and adjusting insulin accordingly) (OR [95% CI] 2.508 [1.500-4.191] P < .001).African adults with T1DM have suboptimal glycemic control with almost one-quarter reporting hospitalization within the preceding year. Most patients felt comfortable with self-adjustment of insulin dose but said that the cost of test strips was the main factor that limited regular monitoring. Reducing direct costs of testing strips and insulin, and improving education will address major challenges within these settings.

Persistent poor glycaemic control in individuals with type 2 diabetes in developing countries: 12 years of real-world evidence of the International Diabetes Management Practices Study (IDMPS)

AIMS/HYPOTHESIS

We evaluated the secular trend of glycaemic control in individuals with type 2 diabetes in developing countries, where data are limited.

METHODS

The International Diabetes Management Practices Study provides real-world evidence of patient profiles and diabetes care practices in developing countries in seven cross-sectional waves (2005-2017). At each wave, each physician collected data from ten consecutive participants with type 2 diabetes during a 2 week period. The primary objective of this analysis was to evaluate trends of glycaemic control over time.

RESULTS

A total of 66,088 individuals with type 2 diabetes were recruited by 6099 physicians from 49 countries. The proportion of participants with HbA_1c <53 mmol/mol (<7%) decreased from 36% in wave 1 (2005) to 30.1% in wave 7 (2017) (p < 0.0001). Compared with wave 1, the adjusted ORs of attaining HbA_1c ≤64 mmol/mol (≤8%) decreased significantly in waves 2, 5, 6 and 7 (p < 0.05). Over 80% of participants received oral glucose-lowering drugs, with declining use of sulfonylureas. Insulin use increased from 32.8% (wave 1) to 41.2% (wave 7) (p < 0.0001). The corresponding time to insulin initiation (mean ± SD) changed from 8.4 ± 6.9 in wave 1 to 8.3 ± 6.6 years in wave 7, while daily insulin dosage ranged from 0.39 ± 0.21 U/kg (wave 1) to 0.33 ± 0.19 U/kg (wave 7) for basal regimen and 0.70 ± 0.34 U/kg (wave 1) to 0.77 ± 0.33 (wave 7) U/kg for basal-bolus regimen. An increasing proportion of participants had ≥2 HbA_1c measurements within 12 months of enrolment (from 61.8% to 92.9%), and the proportion of participants receiving diabetes education (mainly delivered by physicians) also increased from 59.0% to 78.3%.

CONCLUSIONS

In developing countries, glycaemic control in individuals with type 2 diabetes remained suboptimal over a 12 year period, indicating a need for system changes and better organisation of care to improve self-management and attainment of treatment goals.

Metabolic health in the Middle East and north Africa

The Middle East and north Africa are home to different populations with widely varying cultures, histories, and socioeconomic settings. Hence, their health status, health management, and access to appropriate health care differ accordingly. In this Review, we examine data on the historical and prospective status of metabolic diseases in this region including obesity, diabetes, hypertension, dyslipidaemia, and non-alcoholic fatty liver disease. Women in the Middle East and north Africa have the highest risk of metabolic diseases of all women globally, whereas men rank second of all men in this respect. Metabolic risk factors are responsible for more than 300 deaths per 100 000 individuals in this region, compared with a global mean of fewer than 250. Physical inactivity, especially in women, and an unhealthy diet (ie, low consumption of whole grains, nuts, and seafoods) stand out. More than one in every three women are obese in most countries of the region. Prevention programmes have not fully been achieved in most of these countries and the projected future is not optimistic. Comprehensive surveillance and monitoring of metabolic diseases, robust multisectoral systems that support primordial and primary preventions, continuous education of health-care providers, as well as collaboration between countries for joint projects in this region are urgently needed to overcome the paucity of data and to improve the metabolic health status of inhabitants in the Middle East and north Africa.

The burden and correlates of multiple cardiometabolic risk factors in a semi-urban population of Nepal: a community-based cross-sectional study

This study assessed the burden and correlates of three cardiometabolic risk factors, (hypertension, diabetes, and overweight/obesity), and their possible clustering patterns in a semi-urban population of Nepal. Data were obtained from a community-based management of non-communicable disease in Nepal (COBIN) Wave II study, which included 2,310 adults aged 25-64 years in a semi-urban area of Pokhara Metropolitan City of Nepal, using the World Health Organization-STEPS questionnaire. Unadjusted and adjusted binary logistic regression models were used to study the correlates of the individual risk factors and their clustering. The prevalence of hypertension, diabetes, and overweight/obesity was 34.5%, 11.7%, and 52.9%, respectively. In total, 68.2% of the participants had at least one risk factor and many participants had two risks in combination: 6.8% for 'hypertension and diabetes', 7.4% for 'diabetes and overweight/obesity' and 21.4% for 'hypertension and overweight/obesity'. In total, 4.7% had all three risk factors. Janajati ethnicity (1.4-2.1 times), male gender (1.5 times) and family history of diabetes (1.4-3.4 times) were associated with presence of individual risk factors. Similarly, Janajati ethnicity (aOR: 4.31, 95% CI: 2.53-7.32), current smoking (aOR: 4.81, 95% CI: 2.27-10.21), and family history of diabetes (aOR: 4.60, 95% CI: 2.67-7.91) were associated with presence of all three risk factors. Our study found a high prevalence of all single and combined cardiometabolic risk factors in Nepal. It underlines the need to manage risk factors in aggregate and plan prevention activities targeting multiple risk factors.

Treat-to-target HbA1c and lipid profile to prolong β-cell mass/function and optimize treatment goal attainment

BACKGROUND

To evaluate the relation between different serum lipid fractions and other known barriers to attain the HbA_1c  ≤ 7.0% (53 mmol/mol) target.

METHODS

Data on 2719 patients with type 2 diabetes were collected from the five waves of the International Diabetes Mellitus Practice Study implemented in Argentina (2006 to 2012) including demographic/socioeconomic profile, clinical, metabolic (HbA_1c and serum lipids) data, and treatment type and also, percentage of treatment goal attainment. Descriptive statistical analyses included ANOVA, χ² test, and Fisher exact test and univariate and multivariate logistic regression analyses, which identified predictive factors for HbA_1c  ≤ 7% (53 mmol/mol).

RESULTS

The average age was 63 years, primary/secondary education, health insurance, 10-year type 2 diabetes duration, most associated with cardiovascular risk factors and some microvascular/macrovascular complications; 94.5% received antihyperglycaemic drugs. Percentage of people on target: HbA_1c 51.2%, blood pressure 23.5%, total cholesterol 62.6%, low-density lipoprotein (LDL) cholesterol 38.9%, and triglycerides 61.1%. HbA_1c on target depended markedly on treatment type: more of those treated with lifestyle changes and significantly fewer of those receiving insulin. Only 4.1% had all parameters simultaneously on target. Multivariate logistic regression analyses showed that achieving HbA_1c  ≤ 7.0% (53 mmol/mol) was associated with higher educational level, shorter diabetes duration, and having reached goals for LDL cholesterol and triglycerides, whereas opposite results were obtained with insulin treatment and longer diabetes duration.

CONCLUSIONS

High LDL cholesterol and triglyceride levels simultaneously potentiate development/progression of chronic complications, exerting this effect in the long term by decreasing β-cell mass/function, thereby making it more difficult to reach HbA_1c values able to prevent complications.

Type 2 diabetes: Prescription patterns and treatment outcomes of IDMPS survey in Argentina

AIM

To assess prescription patterns for treatment of type 2 diabetes (T2D) and their outcomes in the IDMPS survey in Argentina.

METHODS

Data from 2551 people with T2D recruited from 210 physicians participating in IDMPS surveys in Argentina (2006 to 2012 waves) were recorded, including medical history, medications, glycemic control, blood pressure, and lipid status.

RESULTS

Most people were treated with oral glucose-lowering drugs (OGLDs) (65%), followed by combinations of these drugs plus insulin (22%) and only insulin (13%). These percentages varied according to T2D duration, the frequency of OGLDs decreasing while contrastingly and only insulin increasing (under 5 years versus over 10 years of disease duration, respectively). Average systolic blood pressure (SBP), HbA1c and LDL-c were significantly higher in patients treated with insulin either alone or associated with OGLDs. The percentage of people at target values for these parameters was also lower in these two groups. The percentage of people that reached simultaneous goal treatment values for BP, HbA1c and LDL-c levels was markedly low.

CONCLUSION

Prescription patterns for treatment of T2D follows a chronological trend and the percentage of people at goal values (HbA1c, BP and LDL-c values) was significantly lower in people receiving insulin. These data must be carefully considered by health and academic authorities in order to implement effective strategies to modify this situation.

National rates of emergency department visits associated with diabetes in Saudi Arabia, 2011-2015

BACKGROUND

Despite the fact that diabetes is an important component of the burden of disease on the individual and on the national healthcare systems in Saudi Arabia, knowledge of the volume of emergency department (ED) visits for diabetes is unclear.

OBJECTIVE

Examine changes in ED visit rates associated with diabetes.

DESIGN

Retrospective.

SETTINGS

Governmental hospitals.

METHODS

Publicly available records of health statistics published by the Saudi Ministry of Health from 2011 through 2015 were used to extract data on ED visits related to diabetes. ED visits associated with diabetes were compared over time and by gender. We calculated diabetes-specific rates per 10000 persons for each sex category by dividing the total number of diabetes-associated ED visits in that category by the sex-specific population. We calculated the rate difference (RD) with 95% CI between 2011 and 2015.

MAIN OUTCOME MEASURES

Diabetes-specific rates per 10000 persons for each sex category.

RESULTS

Total annual visits to the ED for management of diabetes increased from 617683 cases in 2011 to 748605 in 2015. The annual number of ED visits associated with diabetes increased by 21% over the study period (20% for males and 23% for females). Compared to males, females had a larger increase in visit rates from 240.5 to 249.8 visits per 10000 women over the study years (RD, 9.6 per 10000 persons, 95% CI -16.4 to 26.6 versus 5.7 per 10 000 persons, 95% CI-13.6 to 18.3 ; P=.01).

CONCLUSION

Although diabetes-associated ED visit rates dramatically increased in 2012, they remained relatively stable after 2012 to the end of the study period. More effective preventive diabetes programs that prevent the use of ED visits and other expensive healthcare resources among people with diabetes are needed.

LIMITATIONS

We had no information on the specific indications for the reported ED visits. These estimates may represent a lower bound on ED visits associated with diabetes since the private sector was not included.

CONFLICT OF INTEREST

None.

Impact of diabetes education and self-management on the quality of care for people with type 1 diabetes mellitus in the Middle East (the International Diabetes Mellitus Practices Study, IDMPS)

AIMS

Self-management (self-monitoring of blood glucose, plus self-adjustment of insulin dose) is important in diabetes care, but its complexity presents a barrier to wider implementation, which hinders attainment and maintenance of glycemic targets. More evidence on self-management is needed to increase its implementation and improve metabolic outcomes.

METHODS

Data from 1316 participants with type 1 diabetes mellitus who were enrolled from Middle East countries into the International Diabetes Management Practices Study (IDMPS), a multinational observational survey, were analyzed to assess the impact of education on disease management and outcomes.

RESULTS

A majority (78%) of participants failed to achieve glycemic target (HbA_1c < 7.0% [<53 mmol/mol]). Participants who had received diabetes education (59%) were more likely to practice self-management than those who had not (odds ratio [OR]: 2.51; 95% confidence interval [CI]: 1.7-3.69; p < 0.001), and those who practiced self-management were more likely to attain target HbA_1c than those who did not (OR: 1.49; 95% CI: 1.06-2.09; p = 0.023).

CONCLUSIONS

These relationships between diabetes education, self-management and glycemic control suggest that diabetes education provides knowledge and skills to optimize self-management, favoring HbA_1c target attainment. Middle East health authorities should search for ways to facilitate access to diabetes education to optimize treatment outcomes.

Direct and indirect costs of diabetes mellitus in Mali: A case-control study

Background

Diabetes mellitus (DM) is one of the most burdensome chronic diseases and is associated with shorter lifetime, diminished quality of life and economic burdens on the patient and society as a result of healthcare, medication, and reduced labor market participation. We aimed to estimate the direct (medical and non-medical) and indirect costs of DM and compare them with those of people without DM (ND), as well as the cost predictors.

Methods and findings

Observational retrospective case–control study performed in Mali.

Participants were identified and randomly selected from diabetes registries. We recruited 500 subjects with DM and 500 subjects without DM, matched by sex and age. We conducted structured, personal interviews. Costs were expressed for a 90-day period. Direct medical costs comprised: inpatient stays, ICU, laboratory tests and other hospital visits, specialist and primary care doctor visits, others, traditional practitioners, and medication. Direct non-medical costs comprised travel for treatment and paid caregivers. The indirect costs include the productivity losses by patients and caregivers, and absenteeism. We estimate a two-part model by type of service and a linear multiple regression model for the total cost. We found that total costs of persons with DM were almost 4 times higher than total cost of people without DM. Total costs were $77.08 and $281.92 for ND and DM, respectively, with a difference of $204.84.

Conclusions

Healthcare use and costs were dramatically higher for people with DM than for people with normal glucose tolerance and, in relative terms, much higher than in developed countries.

Resource use associated with type 2 diabetes in Africa, the Middle East, South Asia, Eurasia and Turkey: results from the International Diabetes Management Practice Study (IDMPS)

OBJECTIVE

Type 2 diabetes (T2D) and its complications form a global healthcare burden but the exact impact in some geographical regions is still not well documented. We describe the healthcare resource usage (HRU) associated with T2D in Africa, the Middle East, South Asia, Eurasia and Turkey.

RESEARCH DESIGN AND METHODS

In the fifth wave of the International Diabetes Management Practices Study (IDMPS; 2011-2012), we collected self-reported and physician-reported cross-sectional data from 8156 patients from 18 countries across 5 regions, including different types of HRU in the previous 3-6 months. Negative binomial regression was used to identify parameters associated with HRU, using incidence rate ratios (IRRs) to express associations.

RESULTS

Patients in Africa (n=2220), the Middle East (n=2065), Eurasia (n=1843), South Asia (n=1195) and Turkey (n=842) experienced an annual hospitalization rate (mean±SD) of 0.6±1.9, 0.3±1.2, 1.7±4.1, 0.4±1.5 and 1.3±2.7, respectively. The annual number of diabetes-related inpatient days (mean±SD) was 4.7±22.7, 1.1±6.1, 16.0±30.0, 1.5±6.8 and 10.8±34.3, respectively. Despite some inter-regional heterogeneity, macrovascular complications (IRRs varying between 1.4 and 8.9), microvascular complications (IRRs varying between 3.4 and 4.3) and, to a large extent, inadequate glycemic control (IRRs varying between 1.89 and 10.1), were independent parameters associated with hospitalization in these respective regions.

CONCLUSIONS

In non-Western countries, macrovascular/microvascular complications and inadequate glycemic control were common and important parameters associated with increased HRU.

Possible approaches to CYP2C9-guided prescription of sulfonylureas in Russia

AIM

To evaluate a possible role of CYP2C9 genotyping for sulfonylureas (SUs) prescription in Russia.

MATERIALS & METHODS

We have collected the current data on correlation between SUs pharmacodynamics and CYP2C9 polymorphisms. We have evaluated the frequency of CYP2C9 polymorphisms in Russia by reviewing the literature published from 2004 to 2015 on Russian CYP2C9.

RESULTS

The genotype *1/*1, which confers risk for treatment failure, has a higher frequency (81.92%) in the non-Caucasians than that (64.92%) in the Caucasians. The Caucasians have a frequency (3.58%) of the poor metabolizers (*2/*2, *2/*3 and *3/*3) eight-times higher than that (0.44%) in the non-Caucasians, predisposing an increased risk of hypoglycemia.

CONCLUSION

Considering the received data and the existed knowledge on CYP2C9 influence on SUs pharmacokinetics and pharmacodynamics, we propose a possible approach to CYP2C9-guided SUs prescription for Russians.

Management of diabetes in Morocco: results of the International Diabetes Management Practices Study (IDMPS) - wave 5

OBJECTIVES

The International Diabetes Mellitus Practice Study (IDMPS) is a 5-year survey documenting changes in diabetes treatment practices in developing countries. The primary objective of this survey was to assess the therapeutic management of type 2 diabetes mellitus (T2DM) in real-life medical practice. The secondary objectives were to evaluate the clinical management of type 1 diabetes mellitus (T1DM) and to assess the proportion of all diabetic patients failing to reach the glycated haemoglobin (HbA1c) <7% target.

METHODS

Data were analysed for 738 patients (240 with T1DM and 498 with T2DM) included in wave 5 of the IDMPS in Morocco in 2011.

RESULTS

Nearly two-thirds (61%) of T2DM patients were treated with oral glucose-lowering drugs (OGLDs) alone, 13.1% were treated with insulin alone and 23.3% were treated with OGLDs plus insulin. Insulin use was less frequent, was initiated later and involved a greater use of premixes versus basal/prandial schedules compared to other populations evaluated in the IDMPS. The majority (92.5%) of T1DM patients were treated with insulin alone and the remainder received insulin plus an OGLD. Insulin protocols included basal + prandial dosing (37.5%) and premix preparations (41.3%). The recommended target of HbA1c <7% was achieved by only 22.2% of T1DM patients and 26.8% of T2DM patients. More macrovascular but fewer microvascular complications were reported in T2DM compared to T1DM patients. Late complications increased with disease duration so that 20 years after diagnosis, 75.7% of T2DM patients were found to have at least one late complication.

CONCLUSIONS

The clinical burden of diabetes is high in Morocco and the majority of patients do not achieve the recommended glycaemia target, suggesting that there is a huge gap between evidence-based diabetic management and real-life practice. Better education of patients and improved compliance with international recommendations are necessary to deliver a better quality of diabetic care.

Gender, diabetes education, and psychosocial factors are associated with persistent poor glycemic control in patients with type 2 diabetes in the Joint Asia Diabetes Evaluation (JADE) program

BACKGROUND

Factors associated with persistent poor glycemic control were explored in patients with type 2 diabetes under the Joint Asia Diabetes Evaluation (JADE) program.

METHODS

Chinese adults enrolled in JADE with HbA1c ≥8% at initial comprehensive assessment (CA1) and repeat assessment were analyzed. The improved group was defined as those with a ≥1% absolute reduction in HbA1c, and the unimproved group was those with <1% reduction at the repeat CA (CA2).

RESULTS

Of 4458 enrolled patients with HbA1c ≥8% at baseline, 1450 underwent repeat CA. After a median interval of 1.7 years (interquartile range[IQR] 1.1-2.2) between CA1 and CA2, the unimproved group (n = 677) had a mean 0.4% (95% confidence interval [CI] 0.3%, 0.5%) increase in HbA1c compared with a mean 2.8% reduction (95% CI -2.9, -2.6%) in the improved group (n = 773). The unimproved group had a female preponderance with lower education level, and was more likely to be insulin treated. Patients in the improved group received more diabetes education between CAs with improved self-care behaviors, whereas the unimproved group had worsening of health-related quality of life at CA2. Apart from female gender, long disease duration, low educational level, obesity, retinopathy, history of hypoglycemia, and insulin use, lack of education from diabetes nurses between CAs had the strongest association for persistent poor glycemic control.

CONCLUSIONS

These results highlight the multidimensional nature of glycemic control, and the importance of diabetes education and optimizing diabetes care by considering psychosocial factors.

Patients' empowerment, physicians' perceptions, and achievement of therapeutic goals in patients with type 1 and type 2 diabetes mellitus in Mexico

BACKGROUND

Physicians' perception may not parallel objective measures of therapeutic targets in patients with diabetes. This is an issue rarely addressed in the medical literature. We aimed to analyze physicians' perception and characteristics of adequate control of patients with diabetes.

PATIENTS AND METHODS

We studied information on physicians and their patients who participated in the third wave of the International Diabetes Management Practices Study registry in Mexico. This analysis was performed on 2,642 patients, 203 with type 1 diabetes mellitus (T1DM) and 2,439 with type 2 diabetes mellitus (T2DM), treated by 200 physicians.

RESULTS

The patients perceived at target had lower hemoglobin A1c (HbA1c) and fasting blood glucose than those considered not at target. However, overestimation of the frequency of patients with HbA1c <7% was 41.5% in patients with T1DM and 31.7% in patients with T2DM (underestimation: 2.8% and 8.0%, respectively). The agreement between the physicians' perception and the class of HbA1c was suboptimal (κ: 0.612). Diabetologists and endocrinologists tested HbA1c more frequently than primary care practitioners, internists, or cardiologists; however, no differences were observed in mean HbA1c, for both T1DM (8.4% vs 7.2%, P=0.42) and T2DM (8.03% vs 8.01%, P=0.87) patients. Nevertheless, insulin users perceived at target, who practiced self-monitoring and self-adjustment of insulin, had a lower mean HbA1c than patients without these characteristics (mean HbA1c in T1DM: 6.8% vs 9.6%, respectively; mean HbA1c in T2DM: 7.0% vs 10.1%, respectively).

CONCLUSION

Although there is a significant physicians' overestimation about the optimal glycemic control, this global impression and characteristics of patients' empowerment, such as self-monitoring and self-adjustment of insulin, are associated with the achievement of targets.

Patterns of Care and Treatment Target Success among Persons with Type 2 Diabetes Mellitus in Dubai: A Retrospective Cohort Study

OBJECTIVES

Despite the high prevalence of type 2 diabetes mellitus (T2DM), few data exist describing its management in Dubai. This study characterized the treatment and estimated levels of glycemic, lipid, and blood pressure control among a sample with T2DM at a large Dubai Hospital.

METHODS

This retrospective cohort study systematically sampled charts from adults seeking care for T2DM from October 2009 to March 2010 until the target (N = 250) was reached. Data on patient characteristics, pharmacotherapy, complications, and laboratory testing were abstracted until September 2011. The frequency of treatments and modifications over the period was calculated, and measures of glycosylated hemoglobin A_1c, low-density lipoprotein, and blood pressure control were compared with guideline targets. Frequencies of complications were compared according to treatment type.

RESULTS

One-third of the cohort comprised men, and the mean age was 58 years. At enrolment, the mean time from T2DM diagnosis was nearly 15 years and 74% had received insulin. During the study period, the most common regimens were insulin + oral combinations (55%) and oral combination therapy (39%). Overall, 67% received any insulin therapy during the study; and by study end, 78% had received insulin at any time. At the most recent assessment, guideline targets for glycosylated hemoglobin A_1c, blood pressure, and low-density lipoprotein were met by 23%, 29%, and 71%, respectively. Complications were more frequent among those treated with combination or insulin therapies.

CONCLUSIONS

This study provides baseline data from Dubai for future comparisons of the effectiveness of new treatments, and to better understand the humanistic and economic burden of T2DM and its complications.

An analysis of the cost-effectiveness of starting insulin detemir in insulin-naïve people with type 2 diabetes

AIMS

There is limited evidence with respect to the cost-effectiveness of starting insulin in people with diabetes outside the 'western' world. The aim of this study was to assess the cost-effectiveness of starting basal insulin treatment with insulin detemir in people with type 2 diabetes (T2D) inadequately controlled on oral glucose-lowering drugs (OGLDs) in Mexico, South Korea, India, Indonesia, and Algeria.

METHODS

The IMS CORE Diabetes Model was used to project clinical and cost outcomes over a 30-year time horizon. Clinical outcomes, baseline characteristics and health state utility data were taken from the A1chieve study. A 1-year analysis was also conducted based on treatment costs and quality-of-life data. Incremental cost-effectiveness ratios (ICERs) were expressed as a fraction of GDP per capita, and WHO-CHOICE recommendations (ICER < 3.0) used to define cost-effectiveness.

RESULTS

Starting insulin detemir was associated with a projected increase in life expectancy (≥1 year) and was considered cost-effective in all of the studied populations with ICERs of -0.02 (Mexico), 0.00 (South Korea), 0.48 (India), 0.12 (Indonesia), and 0.88 (Algeria) GDP/quality-adjusted life-year. Cost-effectiveness was maintained after conducting sensitivity analyses in the 30-year and 1-year analyses. A projected increase in treatment costs was partially offset by a reduction in complications. The difference in overall costs between insulin detemir and OGLDs alone was USD518, 1431, 3510, 15, and 5219, respectively.

CONCLUSION

Changes in clinical outcomes associated with starting insulin detemir in insulin-naïve individuals with T2D resulted in health gains that made the intervention cost-effective in five countries with distinct healthcare resources.

The biosimilar insulin landscape: current developments

Biosimilar insulins have the potential to increase access to treatment among patients with diabetes mellitus, reduce treatment costs, and expand market competition. The patents for several insulins are soon to expire, meaning there is room for copies of these products--or 'biosimilars'--to join the marketplace. It is vital that similar safety and efficacy to the innovator product is demonstrated for biosimilars. This presents many possible manufacturing and regulatory challenges. Complex manufacturing processes mean that even small differences between manufacturers can have a potential impact on the final product. Several companies are currently developing biosimilar insulins or are already producing these products in emerging markets with different regulatory requirements. For insulin biosimilars to be licensed in more established markets, manufacturers will need to meet the rigid criteria set out by agencies such as the European Medicines Agency and US Food and Drug Administration, and fulfill several pre-clinical, clinical, and pharmacovigilance surveillance criteria. As a result of differing regulatory requirements, there are possible gaps in the publically available clinical data to support the safety and efficacy of biosimilar insulins from around the world current as of July 2014. This review summarizes the current biosimilar insulin landscape.

Health outcomes in diabetics measured with Minnesota Community Measurement quality metrics

OBJECTIVE

Our objective was to understand the relationship between optimal diabetes control, as defined by Minnesota Community Measurement (MCM), and adverse health outcomes including emergency department (ED) visits, hospitalizations, 30-day rehospitalization, intensive care unit (ICU) stay, and mortality.

PATIENTS AND METHODS

In 2009, we conducted a retrospective cohort study of empaneled Employee and Community Health patients with diabetes mellitus. We followed patients from 1 September 2009 until 30 June 2011 for hospitalization and until 5 January 2014 for mortality. Optimal control of diabetes mellitus was defined as achieving the following three measures: low-density lipoprotein (LDL) cholesterol <100 mg/mL, blood pressure <140/90 mmHg, and hemoglobin A1c <8%. Using the electronic medical record, we assessed hospitalizations, ED visits, ICU stays, 30-day rehospitalizations, and mortality. The chi-square or Wilcoxon rank-sum tests were used to compare those with and without optimal control. We used Cox proportional hazard models to estimate the associations between optimal diabetes mellitus status and each outcome.

RESULTS

We identified 5,731 empaneled patients with diabetes mellitus; 2,842 (49.6%) were in the optimal control category. After adjustment, we observed that non-optimally controlled patients had higher risks for hospitalization (hazard ratio [HR] 1.11; 95% confidence interval [CI] 1.00-1.23), ED visits (HR 1.15; 95% CI 1.06-1.25), and mortality (HR 1.29; 95% CI 1.09-1.53) than diabetic patients with optimal control. No differences were observed in ICU stay or 30-day rehospitalization.

CONCLUSION

Diabetic patients without optimal control had higher risks of adverse health outcomes than those with optimal control. Patients with optimal control defined by the MCM were associated with decreased morbidity and mortality.

Delivery of integrated diabetes care using logistics and information technology--the Joint Asia Diabetes Evaluation (JADE) program

Diabetes is a global epidemic, and many affected individuals are undiagnosed, untreated, or uncontrolled. The silent and multi-system nature of diabetes and its complications, with complex care protocols, are often associated with omission of periodic assessments, clinical inertia, poor treatment compliance, and care fragmentation. These barriers at the system, patient, and care-provider levels have resulted in poor control of risk factors and under-usage of potentially life-saving medications such as statins and renin-angiotensin system inhibitors. However, in the clinical trial setting, use of nurses and protocol with frequent contact and regular monitoring have resulted in marked differences in event rates compared to epidemiological data collected in the real-world setting. The phenotypic heterogeneity and cognitive-psychological-behavioral needs of people with diabetes call for regular risk stratification to personalize care. Quality improvement initiatives targeted at patient education, task delegation, case management, and self-care promotion had the largest effect size in improving cardio-metabolic risk factors. The Joint Asia Diabetes Evaluation (JADE) program is an innovative care prototype that advocates a change in clinic setting and workflow, coordinated by a doctor-nurse team and augmented by a web-based portal, which incorporates care protocols and a validated risk engine to provide decision support and regular feedback. By using logistics and information technology, supported by a network of health-care professionals to provide integrated, holistic, and evidence-based care, the JADE Program aims to establish a high-quality regional diabetes database to reflect the status of diabetes care in real-world practice, confirm efficacy data, and identify unmet needs. Through collaborative efforts, we shall evaluate the feasibility, acceptability, and cost-effectiveness of this "high tech, soft touch" model to make diabetes and chronic disease care more accessible, affordable, and sustainable.

The burden of diabetes in Argentina

OBJECTIVE

To measure the economic burden of diabetes in Argentina by age, gender and region for the year 2005, in disability-adjusted life years (DALYs).

METHODS

DALYs were estimated by the sum of years of life lost due to premature death (YLL) and years of life lived with disability (YLD).

RESULTS

In the population studied (20 to 85 years), the burden of diabetes without complications was 1.3 million DALYs, 85% of which were caused by disabilities. Whereas mortality rates (YLL) increased as a function of age, YLD showed the opposite relationship. Women had higher burden of disease values, represented by 51 and 61% of YLL and YLD, respectively, independently of age.

CONCLUSIONS

Our results demonstrate that disabilities are a key component of diabetes burden; its regular and systematic estimation would allow to design effective prevention strategies, to assess the impact of their implementation and to optimize resource allocation based on objective evidence.

Use of medical services and medicines attributable to diabetes in Sub-Saharan Africa

Background

Although the large majority of persons with diabetes and other non-communicable diseases (NCDs) lives and dies in low- and middle-income countries, the prevention and treatment of diabetes and other NCDs is widely neglected in these areas. A contributing reason may be that, unlike the impacts of acute and communicable diseases, the demands on resources imposed by diabetes is not superficially obvious, and studies capable of detecting these impacts have not be done.

Methods

To ascertain recent use of medical services and medicines and other information about the impact of ill-health, we in 2008–2009 conducted structured, personal interviews with 1,780 persons with diagnosed diabetes (DMs) and 1,770 matched comparison subjects (MCs) without diabetes in Cameroon, Mali, Tanzania and South Africa. We sampled DMs from diabetes registries and, in Cameroon and South Africa, from attendees at outpatient diabetes clinics. To recruit MCs, we asked subjects with diabetes to identify five persons living nearest to them who were of the same sex and approximate age. We estimated diabetes impact on medical services use by calculating ratios and differences between DMs and MCs, testing for statistical significance using two-stage multivariable hurdle models.

Findings

DMs consumed 12.95 times more days of inpatient treatment, 7.54 times more outpatient visits, and 5.61 times more medications than MCs (all p<0.001). DMs used an estimated 3.44 inpatient days per person per year, made 10.72 outpatient visits per person per year (excluding traditional healers), and were taking an average of 2.49 prescribed medicines when interviewed.

Conclusions

In Sub-Saharan Africa, the relative incremental use of medical care and medicines associated with diagnosed diabetes is much greater than in industrialized countries and in China. Published calculations of the health-system impact of diabetes in Africa are dramatic underestimates. Although non-communicable diseases like diabetes are commonly thought to be minor problems for health systems and patients in Africa, our data demonstrate the opposite.

Call-to-action: timely and appropriate treatment for people with type 2 diabetes in Latin America

Latin America faces a unique set of challenges in the treatment of type 2 diabetes mellitus (T2DM). This report identifies these challenges and provides a framework for implementation of the strategies, policies and education programs which are needed to optimize the management of this condition. In order to improve future diabetes care, it will be necessary to address existing problems such as limitation of resources, inadequate management of hyperglycemia, and inappropriate education of healthcare team members and people with diabetes. Achieving these goals will require collaborative efforts by many individuals, groups and organizations. These include policymakers, international organizations, healthcare providers, those responsible for setting medical school curricula, patients and society as a whole. It is anticipated that improved/continuing education of healthcare professionals, diabetes self-management education and development of a team approach for T2DM care will lead to optimization of patient-centered care. Implementation of multicentric demonstration studies and rational use of antidiabetic treatments will be necessary to demonstrate the long-term favorable impact of these strategies upon quality of care, prevention of chronic complications, mortality, healthcare costs and patient quality of life.

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.

Challenges in diabetes management in Indonesia: a literature review

Background and objectives

The expanding diabetes epidemic worldwide could have potentially devastating effects on the development of healthcare systems and economies in emerging countries, both in terms of direct health care costs and loss of working time and disability. This study aims to review evidence on the burden, expenditure, complications, treatment, and outcomes of diabetes in Indonesia and its implications on the current health system developments.

Methods

We conducted a comprehensive literature review together with a review of unpublished data from the Ministry of Health and a public health insurer (Askes). Studies presenting evidence on prevalence, incidence, mortality, costs, complications and cost of complications, treatment, and outcomes were included in the analysis.

Results

A limited number of international, national and local studies on the burden and cost of diabetes in Indonesia were identified. National survey data suggests that in 2007 the prevalence of diabetes was 5.7%, of which more than 70% of cases were undiagnosed. This estimate hides large intracountry variation. There was very limited data available on direct costs and no data on indirect costs. The most commonly-identified complication was diabetic neuropathy.

Discussion

There were a number of limitations in the data retrieved including the paucity of data representative at the national level, lack of a clear reference date, lack of data from primary care, and lack of data from certain regions of the country.

Conclusions

If left unaddressed, the growing prevalence of diabetes in the country will pose a tremendous challenge to the Indonesian healthcare system, particularly in view of the Government’s 2010 mandate to achieve universal health coverage by 2014. Essential steps to address this issue would include: placing diabetes and non-communicable diseases high on the Government agenda and creating a national plan; identifying disparities and priority areas for Indonesia; developing a framework for coordinated actions between all relevant stakeholders.

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.

Cardiovascular diseases and diabetes as economic and developmental challenges in Africa

Current estimates and projections suggest that the burden of cardiovascular diseases (CVDs), diabetes and related risk factors in African countries is important, somewhat unique and rapidly growing. Various segments of the population are affected; however, the group mostly affected is young adults residing in urban areas, and increasingly those in the low socioeconomic strata. The African milieu/environment is compounded by weak health systems, which are unable to cope with the looming double burden of communicable and chronic non-communicable diseases. This review discusses the economic and developmental challenges posed by CVDs and diabetes in countries in Africa. Using several lines of evidence, we demonstrate that the cost of care for major CVDs and diabetes is beyond the coping capacities of individuals, households, families and governments in most African countries. We have reviewed modeling studies by the International Diabetes Federation (IDF) and other major international agencies on the current and projected impact that CVDs and diabetes have on the economy and development of countries in the region. Locally, appropriate strategies to limit the impact of the conditions on the economies and development of countries in Africa are suggested and discussed. These include monitoring diseases and risk factors, and primordial, primary and secondary preventions implemented following a life-course perspective. Structural, logistic, human capacity and organizational challenges to be surmounted during the implementations of these strategies will be reviewed.

Are recommended standards for diabetes care met in Central and South America? A systematic review

AIMS

We evaluated quality of diabetes care in low- and middle-income countries (LMIC) of Central and South America by documenting the ability to meet the guideline-recommended targets. We also identified barriers to achieving goals of treatment and characteristics of successful programs.

METHODS

We searched the National Library of Medicine and Embase databases to systematically compile literature that reported on guideline-recommended processes of care (annual foot, eye, urine examinations, and regular blood glucose testing) and risk factor control (glycemic, blood pressure, and lipid levels) among people with diabetes since 1980. We compared risk factor control across clinic and household populations and benchmarked against the IDF guidelines.

RESULTS

The available literature was largely from Mexico, Jamaica, and Brazil with little data from rural regions or smaller countries. Twenty-nine clinic-based and ten population-based studies showed a consistent failure to meet recommended care goals due to multiple underlying social and economic themes. Across all studies, the proportion of those not meeting targets ranged from 13.0 to 92.2% for glycemic control, 4.6 to 92.0% for blood pressure, and 28.2 to 78.3% for lipids.

CONCLUSIONS

Few studies report quality of diabetes care in LMICs of the Americas, and heterogeneity across studies limits our understanding. Greater regard for audits, use of standardized reporting methods, and an emphasis on overcoming barriers to care are required.

Treatment of type 2 diabetes with saxagliptin: a pharmacoeconomic evaluation in Argentina

BACKGROUND

The increasing prevalence of diabetes and its inadequate management results in a heavy burden of the disease for the patients, the health and the productive system and the overall community. Consequently, it is necessary to have new effective drugs to treat people with diabetes to decrease such burden. DPP-4 inhibitors can help to cope with this demand, but its usage is challenged by its apparent high cost. The aim of the current study was to compare a simulated cost-effectiveness ratio of metformin (MET) plus one drug of the DPP-4 inhibitors family, saxagliptin (SAXA) or sulfonylurea (SU) treatment during a 20-year period, from the perspective of the social security system, in a cohort of people with Type 2 diabetes (T2DM) who did not attain glycosylated hemoglobin treatment target values only with MET.

METHODS

A discrete event simulation model (Cardiff diabetes model) based on UKPDS 68 was used to simulate disease progression and to estimate the economic and health treatment consequences in people with T2DM. The clinical efficacy parameters for SAXA administration were obtained from the literature; local standard costs were considered for drug acquisition, adverse events (AEs), and micro/macrovascular complications. Costs were expressed in US dollars (2009) with an annual 3.5% discount and a 20-year time horizon.

RESULTS

The SAXA + MET treated group had a lower number of non-fatal events than the SU + MET treated group. The model also predicted a lower number of fatal macrovascular events for the SAXA + MET group (149.6 vs. 152.8). The total cost of the SAXA + MET cohort was 15% higher than that of the SU + MET cohort. Treatment with SAXA + MET resulted in a higher number of quality-adjusted life years (QALYs) (9.54 vs. 9.32) and life-years gained (LYGs) (20.84 vs. 20.76) compared to those treated with SU + MET. The incremental cost per QALY and LYG gained was $7,374 and $20,490, respectively.

CONCLUSIONS

According to the criteria proposed by the Commission on Macroeconomics and Health, the use of the combination SAXA + MET is highly cost-effective in Argentina.

Comprehensive risk assessments of diabetic patients from seven Asian countries: The Joint Asia Diabetes Evaluation (JADE) program

BACKGROUND

 The aim of the web-based Joint Asia Diabetes Evaluation (JADE) program is to establish a registry for quality assurance, monitoring, and evaluation.

METHODS

 The JADE electronic portal provides templates for data collection, supplemented by risk stratification, care protocols, and decision support. Herein, data from 3687 patients with Type 2 diabetes, enrolled over 15 months in 2007-2009 from seven Asian countries, are reported.

RESULTS

Of the patients, 46.1% were men, the median (range) age was 58 (15-93 years), and median disease duration was 6.5 (0-71) years; 16.2% had at least one cardiovascular-renal complication (10.0% coronary heart disease, 3.3% stroke, 3.1% peripheral vascular disease, 0.4% end-stage renal disease), 20.4% had diabetic retinopathy, 15.0% had sensory neuropathy, 7.5% had chronic kidney disease, and 20.7% of men had erectile dysfunction. Hypertension, dyslipidemia, and central obesity affected 84.6%, 76.8%, and 53.5% of patients, respectively. Treatment targets were HbA1c <7% in 35.3%, blood pressure <130/80 mmHg in 32.3%, and low-density lipoprotein-cholesterol <2.6 mmol/L in 34.0%. The rate of attaining one, two, and three targets was 38.7%, 23.4%, and 5.4%, respectively. Using the JADE Risk Engine, 60% of patients with clinical complications and 20% of those with multiple risk parameters were predicted to have a major event within 5 years. Older age, short disease duration, adherence to diet, control of other risk factors, and not smoking were independently associated with HbA1c <7% (all P < 0.05).

CONCLUSIONS

 It is possible to use a web-based protocol to establish a registry for risk stratification and facilitate early intervention.

Prevalence of hypertension, obesity, diabetes, and metabolic syndrome in Nepal

Background. This study was carried out to establish the prevalence of cardiovascular risks such as hypertension, obesity, and diabetes in Eastern Nepal. This study also establishes the prevalence of metabolic syndrome (MS) and its relationships to these cardiovascular risk factors and lifestyle. Methods. 14,425 subjects aged 20–100 (mean 41.4 ± 15.1) were screened with a physical examination and blood tests. Both the International Diabetic Federation (IDF) and National Cholesterol Education Programme's (NCEP) definitions for MS were used and compared. Results. 34% of the participants had hypertension, and 6.3% were diabetic. 28% were overweight, and 32% were obese. 22.5% of the participants had metabolic syndrome based on IDF criteria and 20.7% according to the NCEP definition. Prevalence was higher in the less educated, people working at home, and females. There was no significant correlation between the participants' lifestyle factors and the prevalence of MS. Conclusion. The high incidence of dyslipidemia and abdominal obesity could be the major contributors to MS in Nepal. Education also appears to be related to the prevalence of MS. This study confirms the need to initiate appropriate treatment options for a condition which is highly prevalent in Eastern Nepal.

Conducting cost-effectiveness analyses of type 2 diabetes in low- and middle-income countries: can locally generated observational study data overcome methodological limitations?

In low- and middle-income countries, the high personal and economic burden of type 2 diabetes is further compounded by inadequate resources for diabetes care when compared with high-income countries. Health technology assessments (HTAs) aim to inform policy decision makers in their efforts to achieve more effective allocation of resources by providing evidence-based input on new technologies. Within the hierarchy of evidence, randomized controlled trials (RCTs) remain the 'gold standard' used to inform HTAs, but are limited by poor external validity (ie, generalizability to real-world populations). Unlike RCTs, observational studies are able to enrol broader patient populations, but their design renders such studies vulnerable to confounding factors and selection bias. However, it is increasingly recognized that observational studies can complement RCTs by supporting and extending efficacy findings from RCTs to real-world clinical practice, particularly across geographical populations. They can also provide locally relevant baseline and disease natural history data to populate health economic models. Thus, observational data are likely to be of considerable informative value to policy makers in developing countries reaching decisions on diabetes care within an environment of scarce resources.

An approach to implementing international diabetes guidelines

Diabetes is a common, costly and ever-increasing health problem, with chronic complications that result in a heavy socioeconomic burden for people with the disease, the health care system and society (Ringborg et al, 2009). Chronic complications, the major cause of morbidity, premature mortality and costs of diabetes, can be significantly reduced by control of blood glucose and associated cardiovascular risk factors (Ray et al, 2009). The cost of these treatments is within the range of currently accepted preventative interventions (Gæde et al, 2008). Despite the available evidence, prevention strategies have not been widely incorporated into clinical practice and the care received by many people with diabetes is less than optimal worldwide (Chan et al, 2009).