Improving diabetes care

The  Fifth Edition of Diabetes Altlas (2014) published by the International Diabetic Federation, says that the estimated number of adults living with diabetes has soared to 366 million, representing 8.3 per cent of the global adult population. This number is projected to increase to 552 million people by 2030, or 9.9 per cent of adults, which equates to approximately three more people with diabetes every 10 seconds. Diabetes imposes a large economic burden on any  national healthcare system. Estimated figures show healthcare expenditures on diabetes accounted for 11.6 per cent of the total healthcare expenditure in the world in 2010. About 95 per cent of the countries spend 5.0 per cent or more of their total healthcare dollars on diabetes. IDF estimates  also project that global health expenditures to prevent and treat diabetes and its complications surpassed US dollar 376 billion in 2010 and by 2030, this number will exceed some USD490 billion. An average of USD703 per person was depleted on diabetes in 2010 globally. More than three-quarters of the global expenditure in 2010 were used for persons who are between 50 and 80 years of age. Also, more money is expected to be spent on diabetes care for women than for men.
Diabetes Care, a  journal of the American Diabetes Association, highlights areas of recent research on improving  Diabetes  care. These are:
PATIENT-CENTREDNESS: Practice recommendations, whether based on evidence or expert opinion, are intended to guide an overall approach to care. The science and art of medicine come together when the clinician is faced with the task of making treatment recommendations for a patient who would not have met eligibility criteria for the studies on  which guidelines were based. A comprehensive plan is to reduce cardiovascular risk by addressing blood pressure and lipid control, smoking cessation, weight management, and healthy lifestyle changes that include adequate physical activity.
DIABETES ACROSS THE LIFE SPAN: An increasing proportion of patients with type 1 diabetes are adults. Conversely, and for less salutary reasons, the incidence of type 2 diabetes is increasing in children and young  adults. Finally, patients both with type 1 diabetes and type 2 diabetes are living well into older age, a stage of life for which there is little evidence from clinical trials to guide therapy. All these demographic changes highlight another challenge to high-quality diabetes care,which is the need to improve coordination between clinical teams as patients pass through different stages of the life span or the stages of pregnancy (preconception, pregnancy, and postpartum).
ADVOCACY FOR PATIENTS WITH DIABETES:  Advocacy can be defined as active support and engagement to advance a cause or policy. Advocacy in the cause of improving the lives of patients with (or at risk for) diabetes is an ongoing need. Given the tremendous toll that lifestyle factors such as obesity, physical inactivity, and smoking have on the health of patients with diabetes, ongoing and energetic efforts are needed to address and change the societal determinants at the root of these problems.
DIABETES CARE: KEY OBJECTIVES: Diabetes Education Programme is devoted to  maintain an online resource to help healthcare professionals design and implement more effective health care delivery systems for those with diabetes.
Three specific objectives outline the practical strategies:
Objective 1: Optimise provider and team behavior: The care team should prioritise timely and appropriate intensification of lifestyle and/ orpharmaceutical therapy for patients who have not achieved beneficial levels of blood pressure, lipid, or glucose control. Strategies such as explicit goal setting with patients; identifying and addressing language, numeracy, or cultural barriers to care; integrating evidence-based guidelines and clinical information tools into the process of care; and incorporating care management teams including nurses, pharmacists, and other providers  have each been shown to optimise provider and team behaviour and thereby catalyse reductions in A1C, blood pressure, and LDL cholesterol.
Objective 2: Support Patient Behavior Change: Successful diabetes care requires a systematic approach to supporting patients, behaviour change efforts, including healthy lifestyle changes (physical activity, healthy eating, tobacco cessation, weight management, and effective  coping), 2) disease self-management (taking and managing medication and, when clinically appropriate, self-monitoring of glucose and blood pressure), and 3) prevention of diabetes complications (self-monitoring of  foot health; active participation in screening for eye, foot, and renal complications; and immunisations). High-quality diabetes self-management education may be shown to improve patient self-management, satisfaction, and glucose control, so that gains achieved during education  are sustained.
Objective 3: Change the Care System: An institutional priority in most successful care systems is providing a high quality of care . Changes that have been shown to increase quality of diabetes care include basing care on evidence-based guidelines; expanding the role of teams and staff and implementing more intensive disease management strategies; redesigning the care process; implementing electronic health record tools; activating and educating patients; removing financial barriers and reducing patient out-of-pocket costs for diabetes education, eye exams, self-monitoring of blood glucose,and necessary medications; and identifying/developing/engaging community resources and public policy that support healthy lifestyles. Recent initiatives such as the Patient-Centered Medical Home show promise for improving outcomes through coordinated primary care and offer new opportunities for team based chronic disease care Additional strategies to improve diabetes care include reimbursement structures that, in contrast to visit-based billing, reward the provision of appropriate and high-quality care ,and incentives that accommodate personalised care goals.
It is clear that optimal diabetes management requires an organised, systematic approach and the involvement of a coordinated team of dedicated healthcare professionals working in an environment where patient-centred high-quality care is a priority.
TREATMENT GOALS: Some patients and their healthcare providers may not achieve the desired treatment goals. Reassessing the treatment regimen may require evaluation of barriers such as income, health literacy, diabetes-related distress, depression, poverty, and competing demands including those related to family responsibilities and dynamics. Other strategies may include culturally appropriate and enhanced DSME and DSMS, co-management with a diabetes team, referral to a medical social worker for assistance with insurance coverage, medication taking behaviour assessment, or change in pharmacological therapy. Initiation of or increase in self-monitoring of blood glucose, continuous glucose monitoring, frequent patient contact, or referral to a mental health professional or physician with special expertise in diabetes may be useful.
Diabetes is reaching epidemic proportions worldwide. Every year more people are diagnosed with diabetes, yet there are still many (more than 50 per cent) people who have diabetes and do not know it. A small survey has indicated that the prevalence of diabetes in Bangladesh population aged over 15 years is between 2 per cent-5 per cent. This condition is also found in most of the under-developed countries. In Bangladesh, more than 7.0 per cent of the total population are diabetic patients. In this situation, Diabetic Association of Bangladesh, locally known as Bangladesh Diabetic Samity (BADAS) has been able to give services to only 25 per cent of the total diabetic patients. It is planned by the Association that, by the year 2020, about 55 per cent of the total diabetic population will be brought under comprehensive diabetic care. But it is not easy to provide care to over 8.0 million diabetic patients of the country. Commitment, good planning and resource are needed to meet the programme. Generally healthcare service is delivered to episodic nature of disease. But diabetes care needs follow-up and a continued care.
Dr Muhammad Abdul Mazid, formerly a Secretary and Chairman, NBR, is the Chief Coordinator, Diabetic Association of Bangladesh.
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