SYLY- päivät 2014 Helsinki 28.11.2014 Perusterveydenhuollon erilaisten diabeteksen hoitomallien tuloksellisuuden vertailu (painopisteenä tyypin 1 diabetes) Diabeteslääkäri Mikko Honkasalo Nurmijärven terveyskeskus / ptky Karviainen AkaTK / HY
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
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?
Year 2005 Vanha Kouvola 31 399 inhabitants - 15 years of all diabetes care by family doctors Year 2005 Nurmijärvi 35 922 inhabitants - 15 years of centralized care of T1D and most enhancing T2D in PHC DM : 1195 pt Other DM- type: 41 pt excluded 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 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 2010
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
12 11 10 HbA1c, % 9 8 7 6 5 4 Yksittäiset potilaat KAS:n laboratorio VITA-laboratorio - Keskimääräinen ero 0,6 %- yksikköä, vaihtelu 0,1 1,6 %- yksikköä ei voida käynää vertailuun
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).
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 8.15 ± 1.28 8.16 ± 1.28 (mean) 8.28 ± 1.28 8.20 ± 1.28 (mean) HbA1c (%) 89.3 94.3 (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)
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 / Examined (%) Values (Means ± SD) measurement 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.)
T1D Kouvola Nurmijärvi Esh:ta käyttäneiden osuus vv. 2005-2010 Tk:n seurannassa olevien osuus Ei lääkärikontakteja vuoden aikana dm:n hoidon merkeissä (pudokkaat?) 82,5% (141/171) 67,6% (115/170) P 0,05 49,4% (84/171) 61,4% (105/171) P 0,05 19,0% (16/84) 12,4% (13/105) n.s. Kuolleet vv. 2005-2010 3,5% (6/171) 2,9% (5/170) n.s.
Table 2 Average yearly costs of one type 1 and type 2 diabehc pahent ( in 2010 prices) 2 500 Type 1 diabetes 2 220 Type 2 diabetes 2 000 394 1 969 128 1 710 427 PHC outpabent care 1 500 460 87 PHC inpabent care 1 000 500 0 45 1 004 43 529 1 055 1 023 1 038 461 78 295 250 271 150 384 217 229 223 179 8 131 97 184 307 335 150 74 143 165 113 121 192 96 101 136 52 182 52 123 108 136 64 9 72 Kouvola Nurmijärvi Altogether Kouvola Nurmijärvi Altogether Local hospital outpabent care Local hospital inpabent care Central hospital outpabent care Central hospital inpabent care University hospital outpabent care University hospital inpabent care
DM-hoitajan ammattitaito 35 30 25 20 15 Nurmijärvi Kouvola 10 5 0 Erittäin tyytyväinen Tyytyväinen Melko tyytymätön Erittäin tyytymätön n.s.
Lääkärin ammattitaito 40 35 30 25 20 15 Nurmijärvi Kouvola 10 5 0 Erittäin tyytyväinen Tyytyväinen Melko tyytymätön Erittäin tyytymätön P 0,01
Ravitsemusneuvonta 25 20 15 10 Nurmijärvi Kouvola 5 0 Erittäin tyytyväinen Tyytyväinen Melko tyytymätön Erittäin tyytymätön n.s.
Table 3 ProporHon of type 1 diabehc pahents sahsfied with various dimensions of their diabetes care in the two health centres 100 % 90 % 80 % 70 % 60 % 50 % 40 % 30 % 20 % 10 % 0 % P<0,001 64,5 % 84,5 % Professional skills of the personnel 88,1 % 89,3 % SupporBng services (eye examinabons, laboratory etc.) P<0,05 95,3 % 85,5 % 76,3 % 80,0 % Easiness to contact personnel P<0.05 Diabetes care as whole Kouvola Nurmijärvi
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)
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 primary health care units to cribcally evaluate their present model of diabetes care organizabon In Nurmijärvi the yearly savings were about 85000 90000 in the care of T1D compared with Kouvola The role of diabetes nurses may be vitally important to the quality of T1D care?
KysyIävää? Keskusteltavaa? Ismo Pirrniemi 2013