Perusterveydenhuollon erilaisten diabeteksen hoitomallien tuloksellisuuden vertailu (painopisteenä tyypin 1 diabetes)

(1)

Perusterveydenhuollon erilaisten

diabeteksen hoitomallien tuloksellisuuden vertailu (painopisteenä tyypin 1 diabetes)

Diabeteslääkäri Mikko Honkasalo Nurmijärven terveyskeskus / ptky

Karviainen AkaTK / HY

SYLY-‐päivät 2014 Helsinki 28.11.2014

(2)

Sidonnaisuudet

•  Kongressimatka EASD:hen NovarBs Oy:n kustantamana IX/2013

•  Osallistuminen korvausta vastaan BMS Oy:n advisory boardiin III/2013 koskien

dapagliﬂotsiini-‐valmisteNa Forxiga

•  Jäsenenä korvausta vastaan Medtronic Oy:n Nordic Advisory Boardissa v:sta 2013 lähBen

•  Nurmijärven kunnan palveluksessa

diabeteslääkärinä ja endoskopisBna

(3)

Millä parametreilla tyypin 1 diabeteksen hoidon tuloksia voidaan vertailla / arvioida?

•  Laboratoriotulokset? (jos niin mitkä?)

•  Hoidon kaNavuus? (pudokkaiden osuus?)

•  KH-‐suositusten toteutuminen?

•  Vakavien hypoglykemioiden esiintyminen?

•  KomplikaaBoiden esiintyminen (ns. kovat päätetapahtumat – kehiNyvät hitaasB)?

•  PoBlastyytyväisyys?

•  DiabeeBkon elämänlaatu?

(4)

”Vanha” Kouvola 31 399 inhabitants

-‐ 15 years of all diabetes care by family doctors

Nurmijärvi 35 922 inhabitants

-‐ 15 years of centralized care of T1D and most enhancing T2D in PHC

DM : 1195 pt DM: 1170 pt

T1D: 171 pt f/m 42.7/57.3%

44.4±14.2 yrs

T2D: 958 pt f/m 50.1/49.9%

66.1±10.8 yrs

T1D: 170 pt f/m 38.8/61.2%

44.1±13.5 yrs

T2D: 932 pt f/m 47.7/52.3%

64.4±10.9 yrs Other DM-‐type: 41 pt

excluded Year 2005

Year 2010

Comparison of:

•  Costs of specialist care of diabetes

•  Costs of PHC of diabetes

•  Costs of overall care of diabetes

•  Quality of follow-‐up of diabetes

•  Laboratory and clinical data of diabeBc paBents

•  PaBent saBsfacBon (DM 1)

Year 2005

Year 2010

(5)

HbA _1c

•  Vasta suurempi ero kuin 0,65 % on kliinisesB merkiNävä, pienempi ero voi johtua

menetelmän satunnaisvaihtelusta (Koskinen et al. Diabetes Care 1994)

•  Mikä on HbA _1c :n opBmi? – erilainen eri poBlasryhmissä

•  SLL 16/2007: HbA _1c -‐määritysten tuloksissa on

tasoeroa

(6)

-‐ Keskimääräinen ero 0,6 %-‐yksikköä, vaihtelu 0,1 – 1,6 %-‐yksikköä → ei voida käyNää vertailuun

4 5 6 7 8 9 10 11 12

HbA1c, %

Yksittäiset potilaat

KAS:n laboratorio VITA-laboratorio

(7)

(8)

Severe hypoglycaemia in drug-‐treated diabeHc paHents needs aIenHon:

A populaHon-‐based study. Scand J Prim Health Care 29/2011

Ei eroja vertailukunHen välillä.

Ei eroja perusinsuliinien välillä (glargiini/NPH).

(9)

(10)

(11)

The coverage and the quality of the type 1diabetes care in the two communities. Only the patients who announced themselves to be in the follow-‐‑up of the health centres were included in the evaluation of the proportion of examined patients.

Type 1 diabetes

ExaminaHon / measurement

Examined (%) Values (Medians ± SD)

Kouvola Nurmijärvi Kouvola Nurmijärvi

LDL cholesterol (mmol/l) 71.4 84.8 2.58 ± 0.56 2.48 ± 0.84

(During the latest 1.5 years) (p < 0,05) (n.s.)

BMI 51.2 77.1 24.0 ± 3.5 26.0 ± 5.0

(During the latest year) (p<0.01) p<0.05

HbA1c (%) 89.3 94.3

8.15 ± 1.28 8.16 ± 1.28

(mean)

8.28 ± 1.28 8.20 ± 1.28

(mean)

(During the latest year) (n.s.) (n..s.)

RR (mmHg) 83.3 90.4 139±20 / 80±10 137±18 / 81±10

(During the latest year) (n.s.) (n.s.)

nU-‐alb 58.3 74.3

(During the latest 1,5 years) (p<0.01)

ReHnal photographing 73.8 53.3

(According to naHonal

recommendaHons) (p<0.05)

ExaminaHon of the feet 44.0 88.0

(During the latest 1.5 years) (p<0.01)

(12)

The coverage and the quality of the diabetes care in the two communities.

Only the patients who announced themselves to be in the follow-‐‑up of the health centres were included in the evaluation of the proportion of examined patients.

Type 2 diabetes

ExaminaHon /

measurement

Examined (%) Values (Means ± SD)

Kouvola Nurmijärvi Kouvola Nurmijärvi

LDL cholesterol (mmol/l) 70.0 78.5 2.69±0.79 2.56±0.74

(During the latest 1.5 years) (p<0.01) (n.s.)

BMI 69.5 61.3 30.4±5.4 32.5±6.1

(During the latest year) (p<0.01) (n.s.)

HbA1c (%) 93.2 90.7 7.09±1.11 7.19±1.11

(During the latest year) (n.s.) (n.s.)

RR (mmHg) 91.2 87.0 144±18/80±10 146±17/83±10

(During the latest year) (p<0.05) (p<0.05/syst., p<0.01/diast.)

nU-‐alb 35.2 37.1

(During the latest 1,5 years) (n.s.)

ReHnal photographing 49.2 35.1

(According to naHonal

recommendaHons) (p<0.01)

ExaminaHon of the feet 43.5 43.2

(During the latest 1.5 years) (n.s.)

(13)

Kouvola Nurmijärvi

Esh:ta käyttäneiden

osuus vv. 2005-‐2010 82,5% (141/171) 67,6% (115/170) Tk:n seurannassa olevien

osuus 49,4% (84/171) 61,4% (105/171)

Ei lääkärikontakteja vuoden aikana dm:n hoidon merkeissä (pudokkaat?)

19,0% (16/84) 12,4% (13/105)

Kuolleet vv. 2005-‐2010 3,5% (6/171) 2,9% (5/170) P ˂ 0,05

T1D

P ˂ 0,05

n.s.

(14)

64 182 123

9 136 72 52

335

192 101

52 121

179

150

108

165

136 307

461

384

96

131

113 150

78

143

74 1 004 43 529

184 8 97 128

45

87

217 229 223 394

460

427

295 250 271

0 € 500 € 1 000 € 1 500 € 2 000 € 2 500 €

Kouvola Nurmijärvi Altogether Kouvola Nurmijärvi Altogether

PHC outpaBent care PHC inpaBent care

Local hospital outpaBent care Local hospital inpaBent care Central hospital outpaBent care Central hospital inpaBent care University hospital outpaBent care University hospital inpaBent care

Type 1 diabetes Type 2 diabetes

Average yearly costs of one type 1 and type 2 diabeHc paHent (€ in 2010 prices Table 2 )

1 038 € 1 969 €

1 023 € 1 055 €

1 710 € 2 220 €

(15)

0 5 10 15 20 25 30 35

Erittäin tyytyväinen Tyytyväinen Melko tyytymätön Erittäin tyytymätön

DM-hoitajan ammattitaito

Nurmijärvi Kouvola

n.s.

(16)

0 5 10 15 20 25 30 35 40

Lääkärin ammattitaito

Nurmijärvi Kouvola

P ˂ 0,01

(17)

0 5 10 15 20 25

Ravitsemusneuvonta

Nurmijärvi Kouvola

n.s.

(18)

64,5 %

88,1 %

76,3 % 80,0 %

84,5 % 89,3 %

85,5 % 95,3 %

0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %

Professional skills

of the personnel SupporBng services (eye examinaBons, laboratory etc.)

Easiness to contact personnel

Diabetes care as whole

Kouvola Nurmijärvi P<0,05 P<0.05

ProporHon of type 1 diabeHc paHents saHsﬁed with various dimensions of their diabetes care in the two health centres

Table 3

P<0,001

(19)

Results

•  In Nurmijärvi with centralised diabetes care more type 1 diabeBc paBents were followed-‐up in primary health care than in Kouvola community, where family doctors need more specialist consultaBons. The diﬀerence

resulted in cost savings in the diabetes care of type 1 diabeBc paBents. However, the quality of care was similar, but type 1 diabeBc paBents were more

saBsﬁed with their follow-‐up in the centralised system.

•  Among type 2 diabeBc paBents the centralised

diabetes care resulted in fewer specialist consultaBons, but irrespecBve the model of care, the quality and

costs were nearly similar (32€/pt/year cheaper in

Nurmijärvi)

(20)

Conclusions

•  Our data suggests that diabetes care of T1D paBents can be arranged in primary health care with good quality and paBent saBsfacBon. Cost savings can be achieved due to less need for

specialist consultaBons if GP working at the health centre has good experience and moBvaBon with diabetes care

•  Considering T2D paBents the model of diabetes care organisaBon in PHC had similar eﬀect on the quality of diabetes care and reduced the yearly costs only by 3 %. These data should encourage the

Perusterveydenhuollon erilaisten diabeteksen hoitomallien tuloksellisuuden vertailu (painopisteenä tyypin 1 diabetes)