Proportion of Brazilian diabetes patients that achieve treatment goals: implications for better quality of care

Current State of Diabetes Mellitus Prevalence, Awareness, Treatment, and Control in Latin America: Challenges and Innovative Solutions to Improve Health Outcomes Across the Continent

PURPOSE OF REVIEW

Latin America is the scenario of great inequalities where about 32 million human beings live with diabetes. Through this review, we aimed at describing the current state of the prevalence, awareness, treatment, and control of diabetes mellitus and completion of selected guidelines of care across Latin America and identify opportunities to advance research that promotes better health outcomes.

RECENT FINDINGS

The prevalence of diabetes mellitus has been consistently increasing across the region, with some variation: higher prevalence in Mexico, Haiti, and Puerto Rico and lower in Colombia, Ecuador, Dominican Republic, Peru, and Uruguay. Prevalence assessment methods vary, and potentially underestimating the real number of persons with diabetes. Diabetes unawareness varies widely, with up to 50% of persons with diabetes who do not know they may have the disease. Glycemic, blood pressure, and LDL-C control and completion of guidelines to prevent microvascular complications are not consistently assessed across studies, and the achievement of control goals is suboptimal. On the other hand, multiple interventions, point-of-care/rapid assessment tools, and alternative models of health care delivery have been proposed and tested throughout Latin America. The prevalence of diabetes mellitus continues to rise across Latin America, and the number of those with the disease may be underestimated. However, some local governments are embedding more comprehensive diabetes assessments in their local national surveys. Clinicians and public health advocates in the region have proposed and initiated various multi-level interventions to address this enormous challenge in the region.

Glycaemic benefit of iGlarLixi in insulin-naive type 2 diabetes patients with high HbA1c or those with inadequate glycaemic control on two oral antihyperglycaemic drugs in the LixiLan-O randomized trial

In this post hoc analysis of the randomized controlled LixiLan-O trial in insulin-naive patients with type 2 diabetes mellitus (T2DM) not controlled with metformin, with or without a second oral antihyperglycaemic drug (OAD), the efficacy and safety of the fixed-ratio combination, iGlarLixi (insulin glargine 100 U [iGlar] and lixisenatide [Lixi]), compared to its individual components was assessed in two patient subgroups: group 1) baseline HbA1c ≥9% (n = 134); group 2) inadequate control (HbA1c ≥7.0% and ≤9.0%) despite administration of two OADs at screening (n = 725). Treatment with iGlarLixi resulted in significantly greater reduction in least squares mean HbA1c compared to treatment with iGlar or Lixi alone in both subgroups (group 1: 2.9%, 2.5%, 1.7% and group 2: 1.5%, 1.2%, 0.7%, respectively). Target HbA1c less than 7% was achieved in more than 70% of patients using iGlarLixi in both subgroups, while mitigating the weight gain observed with use of iGlar alone. Rates of hypoglycaemic events were low overall. These results suggest that treatment with iGlarLixi achieves superior glycaemic control compared to treatment with iGlar or Lixi alone in T2DM patients with HbA1c ≥9% or in those inadequately controlled with two OADs.

Quality indicators in type 2 diabetes patient care: analysis per care-complexity level

BACKGROUND

This study was developed to evaluate quality indicators in type 2 diabetes patient care at the Unified Public Health System's primary and tertiary health care centers within a local population.

METHODS

This was a retrospective cohort of 488 patients with type 2 diabetes (148 in each primary health care unit, ESF and UBS, and 192 at the tertiary health care unit) with a 1-year follow-up to evaluate the following care quality indicators: nephropathy, neuropathy and retinopathy tests, yearly lipid profile and nutritional assessments, and an inquiry about tobacco use. The presence of > 50% of the quality of care assessment measures was considered acceptable. Indicators were also evaluated in relation to patients without proper diabetes control (HbA1c > 8.5%).

RESULTS

In the results, a high percentage of patients were excluded specifically for not presenting the two HbA1c tests within a year (n = 208, 58.1% at ESF; n = 225, 58.4% at UBS; and n = 39, 16.9% at the tertiary health care unit). From the included patients, only 7 (4.7%) at ESF, 7 (4.7%) at UBS, and 52 (27.0%) at the tertiary health care unit showed > 50% of the quality criteria covered. When only patients without proper diabetes control were evaluated, none of them at any of the health care units showed all the quality criteria covered.

CONCLUSIONS

Our results show a low percentage of care assessment measures at each evaluated health care unit, pointing out the need to improve the protocols and care lines of diabetic patients.

Heart failure is associated with non-adherence to pharmacotherapy in elderly with type 2 diabetes mellitus in public health system Brazilians

The rising prevalence of T2DM poses a serious threat to human health and the viability of many health care systems around the world. Non-adherence to therapeutic in the T2DM is high, and Brazilian studies of public heath for to identify new variables are scares. The present study explored cardiovascular consequences associated with compliance and non-adherence among T2DM in Brazilian patients seeking medical care in Brazilian basic health unit clinics.

METHODS

This is a cross-sectional study carried out in a city the interior of Sao Paulo state, with patients with T2DM, being municipal PHS users. Data were collected from the computerized system of the municipality for a one single researcher and patient records, and analyzed using the IBM SPSS v.18 statistical package. The response variables was categorized in adherent MGT (>80) and non-adherent MGT (≤80).

RESULTS

The mean age of patients was 63.6 ± 9.5 with predominance for the sex male 66.4% and 42% of patients with T2DM do not adherence to treatment. We found an associated odds ratio (OR) = 2.3 (1.1-5.1) between heart failure and non-adherence in patients with T2DM.

CONCLUSION

Heart failure is a factor associated with non-adherence to treatment in patients with T2DM and in the practice clinical, the screening for heart failure and interventions may improve adherence to pharmacotherapy.

Political party ambitions and type-2 diabetes policy in Brazil and Mexico

In the Americas, next to the United States, Brazil and Mexico have the highest prevalence of type-2 diabetes. In contrast to most studies, this article compares and analyzes the politics behind the implementation of type-2 diabetes self-care management programs (DSM), which is a new area of scholarly research. This article claims that Brazil outpaced Mexico with respect to the implementation of effective DSM programs, the product of positive policy spillover effects associated with the president and governing political party's popular anti-poverty programs, and the enduring legacy of centralized ministry of health financial and human resource assistance to primary care programs in a context of decentralization. Brazil also benefited from having a strong partnership with international health agencies. None of these factors was present in Mexico. Findings suggest that more research needs to go into understanding the complex political and inter-governmental contexts facilitating DSM program implementation, which is a neglected area of research.

DIRECT COSTS OF TYPE 2 DIABETES: A BRAZILIAN COST-OF-ILLNESS STUDY

Objectives:The aim of this study was to evaluate the direct costs of type 2 diabetes mellitus patients treated in a Brazilian public hospital.

Methods:This was an exploratory retrospective cost-of-illness study with quantitative approach, using medical records of patients treated in a public hospital (2012–14), with at least one consultation over a period of 12 months. Data on patient's profile, exams, number of consultations, medications, hospitalizations, and comorbidities were collected. The cost per patient per year (pppy) was calculated as well as the costs related to glycated hemoglobin (HbA1c) values, using thresholds of 7 and 8 percent.

Results:Data of 726 patients were collected with mean age of 62 ± 11 years (68.3 percent female). A total of 67.1 percent presented HbA1c > 7 percent and 44.9 percent > 8 percent. The median cost of diabetes was United States dollar (USD) 197 pppy. The median costs of medication were USD 152.49 pppy, while costs of exams and consultations were USD 40.57 pppy and 8.70 pppy, respectively. Thirty-eight patients (4 percent) were hospitalized and presented a median cost of 3,656 per patient per hospitalization with a cost equivalent to 53.1 percent of total expenses. Total costs of patients with HbA1c ≤ 7 percent were lower for this group and also costs of medications and consultations, whereas for patients with HbA1c ≤ 8 percent, only total costs and costs of medications were lower when compared with HbA1c > 8 percent patients.

Conclusions:Medications and hospitalizations were the major contributor of diabetes expenses. Preventing T2DM, or reducing its complications through adequate control, may help avoid the substantial costs related to this disease.

Quality of Care of Patients with Diabetes in Primary Health Services in Southeast Brazil

Background

Diabetes management involves multiple aspects that go beyond drug therapy as a way of providing high quality care. The objective of this study was to describe quality of care indicators for individuals with diabetes in southeast Brazil and to explore associations among these indicators.

Methods

In this cross-sectional, observational study, health care providers filled out a questionnaire addressing health care structure and processes at 14 primary health care units (PHCUs). Clinical and laboratory data of diabetic patients attending the PHCUs and from patients referred to a secondary health care (SHC) center were collected.

Results

There was a shortage of professionals in 53.8% of the PHCUs besides a high proportion of problems regarding referrals to SHC. At the PHCU, glycated hemoglobin results were available only in half of the medical records. A low rate of adequate glycemic control was also observed. An association between structure and process indicators and the outcomes analyzed was not found.

Conclusion

Major deficiencies were found in the structure and processes of the PHCUs, in addition to unsatisfactory diabetes care outcomes. However, no association between structure, process, and outcomes was found.

Integrated Assessment of Pharmacological and Nutritional Cardiovascular Risk Management: Blood Pressure Control in the DIAbetes and LifEstyle Cohort Twente (DIALECT)

Cardiovascular risk management is an integral part of treatment in Type 2 Diabetes Mellitus (T2DM), and requires pharmacological as well as nutritional management. We hypothesize that a systematic assessment of both pharmacological and nutritional management can identify targets for the improvement of treatment quality. Therefore, we analysed blood pressure (BP) management in the DIAbetes and LifEstyle Cohort Twente (DIALECT). DIALECT is an observational cohort from routine diabetes care, performed at the ZGT Hospital (Almelo and Hengelo, The Netherlands). BP was measured for 15 minutes with one minute intervals. Sodium and potassium intake was derived from 24-hour urinary excretion. We determined the adherence to pharmacological and non-pharmacological guidelines in patients with BP on target (BP-OT) and BP not on target (BP-NOT). In total, 450 patients were included from August 2009 until January 2016. The mean age was 63 ± 9 years, and the majority was male (58%). In total, 53% had BP-OT. In those with BP-NOT, pharmacological management was suboptimal (zero to two antihypertensive drugs) in 62% of patients, and nutritional guideline adherence was suboptimal in 100% of patients (only 8% had a sodium intake on target, 66% had a potassium intake on target, 3% had a sodium-to-potassium ratio on target, and body mass index was <30 kg/m² in 35%). These data show pharmacological undertreatment and a low adherence to nutritional guidelines. Uncontrolled BP is common in T2DM, and our data show a window of opportunity for improving BP control, especially in nutritional management. To improve treatment quality, we advocate to incorporate the integrated monitoring of nutritional management in quality improvement cycles in routine care.

Evaluation, intervention, and follow-up of patients with diabetes in a primary health care setting in Brazil: the importance of a specialized mobile consultancy

BACKGROUND

Studies show that educational interventions improve glycemic control in patients with diabetes mellitus (DM), reducing the occurrence of complications associated with the disease.

OBJECTIVES

To evaluate the effects of a mobile DM consultancy on clinical and laboratory parameters, disease knowledge, and quality of life in patients with type 2 DM (T2DM) at a primary health care network in Brazil.

METHODS

Randomized clinical trial conducted in a city in southern Brazil with 52 patients with T2DM receiving care at a primary health care setting. The intervention lasted for 6 months and consisted of a follow-up with an endocrinologist (five meetings), treatment adjustment based on clinical evaluation and laboratory tests, and educational activities with conversation maps in DM. The statistical analysis included comparison and association tests, considering p values ≤0.05 as statistically significant.

RESULTS

The mean age of the patients was 63.8 years. Most participants were female (63.5 %), had low educational level (59.6 %) and family history of T2DM (71.2 %), used only oral hypoglycemic agents to manage their DM (73.2 %), presented unfavorable anthropometric and laboratory parameters, a high or medium risk of complications (84.6 %), and inadequate glycemic control (67.3 %; with 71 % of the high-risk patients presenting a HbA1c level >9 %). Adjustment in pharmacological treatment was required in 63.5 % of the patients. After the intervention, we observed a significant 0.46 % decrease in mean HbA1c level (p = 0.0218), particularly among individuals with inadequate glycemic control (0.71 %; p = 0.0136). Additionally, there was an increase in disease knowledge scores and a significant decrease in mean body mass index, waist circumference, and disease impact scores.

CONCLUSION

The intervention improved glycemic control and disease knowledge, reduced the values of body mass index and waist circumference, and the impact of the disease on patients' lives. This indicates that care and educational measures improve the experience of the patients with DM and control of the disease.