Healthcare for diabetics: Is the Spanish model good enough?

Diabetes mellitus type 2 has a prevalence of 8% in the general population and 20% in over 65, and if you consider all the complications that arise, it is clear that this is a chronic disease that occurs most in everyday life of health systems. So, having the issue of diabetes well addressed is very important.

The Spanish model of primary health care included, since the beginning of its reform in the early 80s, a holistic model of diabetes care, with timely support from the endocrinologists and probably for this reason, the results recorded today are very satisfactory. See it in the OECD report of 2011, that when the rate of hospitalisations for admissions due to poorly controlled diabetes is analysed, Spain shows the lowest rate out of a group of 24 countries.

On the left side of the graph, where the accumulated data is, we can see that the admission of 3.3 per hundred thousand inhabitants and the year recorded in Spain represents half of the second country on the list, Israel, one-fifth of that of Portugal, one sixth of the U.S. and the UK, and so on, towards the worst performance in the series, which are those of Austria, with admissions of 187.9 per hundred thousand inhabitants a year.

In Catalonia, the CatSalut CMBD database has developed a program for the quality indicators inquiry called MSIQ (Modules for Monitoring Quality Indicators), which has a section on potentially avoidable admissions (Quality Prevention Indicators). The following table is extracted from MSIQ, and there we can observe how in the period 2004-2011, in Catalonia there is a marked improvement of hospitalisations attributed to diabetes or its complications:

Avoidable hospitalizations due to uncontrolled diabetes or its complications
Annual hospitalization rates per hundred thousand inhabitants. Source: MSIQ CatSalut
	2004	2011
Admissions due to uncontrolled diabetes	5,9	2,5
Admissions due to complications of diabetes in the short term	17,8	13,9
Admissions due to complications of diabetes in the long-term	42,5	32,2
Admissions for amputations due to diabetes	22,7	19,9

Creating GEDAPS (Group Study of Diabetes in Primary Care) gave primary care more thrust and more instruments for clinical management of patients with type 2 diabetes. There are two publications (Franch 2009, Mata-Cases 2012) linked to the activities of these groups, and other publications recently appeared in ‘Diabetes Care’ (Vinagre 2012), corroborating that programs for diabetes care from the local primary care units are  in a promising process of continuous improvement.

The following table is an excerpt from the first article (Franch, 2009) which makes a temporal comparison of Spanish data for the period between 1996 and 2007:

Glycated hemoglobin (HbA1c) is a lab test that records the control or lack of control of blood sugar at least 4 weeks prior to the test. Note that having 59% of the diabetic population in figures below 7% of HbA1c (upward trend) and 4.6% in figures above 10% (downward trend) are clearly positive results that do no more than corroborate the efficiency of the ongoing work of the primary care teams on the group of patients with type 2 diabetes; without underestimating the observed improvements in the three complications selected in the table above (retinopathy, foot ulcers and amputations), all three clearly declining. The other two cited articles (Mata-Cases 2012 and Vinagre 2012) are limited to the area of ​​Catalonia, but the results that these show follow the same positive line as the Spanish study GEDAPS (Franch 2009).

However, the Spanish results in the fields of other chronic diseases such as respiratory conditions are less satisfactory. In the OECD report we can see how the 43.9 asthma admissions per hundred thousand inhabitants per year and the 139 EPOC, places Spain on the 16th place and 8th respectively. In both conditions, the number of avoidable admissions is really improved, especially when taking into account the excellent results of the diabetes and the potential of the local primary care model.

Discussion

Health systems today have two concerns that stand out clearly above the others: budget reduction and waste of resources by mismatches in the treatment of chronic patients. For the first of the concerns I do not quite know what to say, but as for the second, I would suggest that for the approach of the patients with chronic diseases, especially the most major ones, the formulas that are functioning so well for diabetes in Spain, be adopted:

1. Featuring exclusively the multidisciplinary primary care: doctors, nurses, physiotherapists, social work and home work; encouraging patients self care whenever possible. 
2. Specialists remote support: pneumologists, cardiologists and geriatricians, but without integrating into the primary care staff.
3. For each of the chronic conditions, consider whether it’s better to make a selection of the most complex patients that take more resources, to develop, if necessary, specific programs with separate staff.
4. And finally, the last but not the least: the purchasing power (the English commissioning) for the primary care team’s responsible for addressing chronicity. This admittedly would be an unproven initiative, at least in Spain.

Bibliographic reference

• OECD (2011), Health at a Glance 2011: OECD Indicators, OECD Publishing. Se puede descargar libremente.
• Franch J, Artola S, Diez J, Mata M. Evolución de los indicadores de calidad asistencial al diabético tipo 2 en atención primaria (1996-2007). Med Clin (Barc) 2010; 135 (13) :600-7.
• Mata-Cases M, Roura-Olmeda P, Berengué-Iglesias M, et al. Fifteen years of continous improvement of quality care of type 2 diabetes mellitus in primary care in Catalonia, Spain. Int J Clin Pract, March 2012; 66,3:289-98.
• Vinagre Y, Mata-Cases M, Hermosilla E, et al. Control of Glycemia and Cardiovascular Risk Factores in Patients With Type 2 Diabetes in Primary Care in Catalonia (Spain). Diabetes Care 2012; 35:774-9.

Jordi Varela
Editor