Evaluación de la calidad de la asistencia al paciente diabético en América Latina / Evaluation of the quality of care for diabetic patients in Latin America

RESUMEN

Objetivos. Hacer un diagnóstico preliminar de la calidad de la atención que reciben las personas con diabetes (DM) en centros tributarios de la red QUALIDIAB y analizar el potencial de esta información y la importancia de la expansión de la red en América Latina y el Caribe. Métodos. Se analizaron 13 513 registros provenientes de centros de atención del subsector público y privado de salud y de la Seguridad Social de Argentina, Brasil, Chile, Colombia, Paraguay y Uruguay (red QUALIDIAB). Se utilizaron indicadores de la calidad de la atención basados en valores de referencia internacionales, una planilla de registro de parámetros clínicos, bioquímicos y terapéuticos y de la tasa de uso de elementos diagnósticos y terapéuticos, un programa para cargar los datos y otro para su análisis estadístico. Resultados. La diabetes tenía una duración < 5 años en alrededor de la mitad de las personas con DM de tipo 1 (DM1) y de tipo 2 (DM2) registradas. El 24% de las personas con DM1 y el 15 % con DM2 tenían glucemias < 4,4 mmol/L, mientras que el 41% con DM1 y el 57% con DM2 tenían glucemias > 7,7 mmol/L. La frecuencia de la asociación de la DM2 con otros factores de riesgo cardiovascular (FRCV) fue la siguiente sobrepeso/obesidad, 59%; hipertensión, 60%; colesterol total > 5,5 mmol/L, 53%; colesterol de las lipoproteínas de alta densidad < 1 mmol/L, 32%; triglicéridos > 1,7 mmol/L, 45%; tabaquismo 13%. El 20% de las personas con DM1 tenían un índice de masa corporal < 19 kg/m2 que probablemente refleje un deficiente control metabólico e hipoinsulinización. La verificación sistemática de indicadores del control metabólico y la detección de FRCV y de complicaciones crónicas de la DM fueron deficientes en el 3 al 75% de los casos. Según los indicadores de educación terapéutica, solo la mitad o la cuarta parte de los participantes podrían desempeñar un papel activo y eficaz en el control y tratamiento de su DM. El 50% de las personas con DM1 son tratadas con combinación de insulinas (NPH + corriente), administrada en dos inyecciones diarias en el 43% de los casos. El 5 y el 9% de los pacientes reciben, respectivamente, 1 y > 3 inyecciones diarias de insulina. El 13% de las personas con DM2 tratan su enfermedad solo con dieta y el 14% solo con insulina. Entre los pacientes tratados con fármacos, los hipoglucemiantes orales más utilizados como monoterapia fueron las sulfonilureas (33%), seguidas por las biguanidas (9%) y su administración combinada (14%). Menos de la mitad de las personas con diabetes reciben farmacoterapia para tratar los FRCV asociados. La frecuencia de las complicaciones microangiopáticas y macroangiopáticas aumentó con la antigüedad de la enfermedad, verificándose los incrementos máximos en la insuficiencia renal y en las amputaciones (alrededor de 7 veces) y los menores en la neuropatía periférica (2 veces) y los accidentes cerebrovasculares (1,6 veces)

ABSTRACT

Objective. To make a preliminary diagnosis of the quality of care that individuals with diabetes mellitus (DM) received in participating centers of the QUALIDIAB network in Latin America and the Caribbean, and to assess the potential usefulness of this information as well as the importance of expanding the QUALIDIAB network. Methods. A total of 13 513 patient records from the QUALIDIAB network were analyzed, from public and private health care entities and from the Social Security systems of Argentina, Brazil, Chile, Colombia, Paraguay, and Uruguay. The study utilized 1) quality-of-care indicators based on international reference values, 2) patient information on clinical, biochemical, and therapeutic parameters and on the rate of use of diagnostic and therapeutic materials, 3) a computer database program, and 4) a software program for statistical analysis. Results. Among the patients studied, about half of them had suffered from diabetes for 5 years or less; this was true both for persons with type 1 diabetes (DM1) and for those with type 2 diabetes (DM2). Of the persons with DM1, 24% of them had a blood glucose level of < 4.4 mmol/L; this was true for 15% of those with DM2. The proportion of persons with a blood glucose level of > 7.7 mmol/L was 41% among those with DM1 and 57% among those with DM2. The frequencies of association between DM2 and other cardiovascular risk factors were overweight/obesity, 59%; hypertension, 60%; total cholesterol > 5.5 mmol/L, 53%; high-density lipoprotein cholesterol < 1 mmol/L, 32%; triglycerides > 1.7 mmol/L, 45%; and smoking, 13%. Of the people with DM1, 20% of them had a body mass index < 19 kg/m2, probably reflecting deficient metabolic control and inadequate insulin intake. The systematic checking of metabolic control, other cardiovascular risk factors, and chronic DM complications was inadequate in from 3% to 75% of the cases, depending on the specific aspect considered. According to various patient-therapy-education indicators, only some one-quarter to one-half of the studied patients could play an active, effective role in DM control and treatment. Of the persons with DM1, 50% of them were treated with a mixed dose of insulin (NPH + regular insulin), administered in two daily injections in 43% of the cases. Among the patients, 5% of them received one daily insulin injection, and 9% of them received three daily insulin injections. Of the people with DM2, 13% of them treated it only with diet and 14% just with insulin. Among the patients receiving drug treatment, the oral hypoglycemics most used in monotherapy were sulfonylureas (33%), biguanides (9%), and a combination of these two (14%). Fewer than half of the people with diabetes received drug therapy for the associated cardiovascular risk factors. The frequency of patients' macroangiopathic and microangiopathic complications increased with the duration of their disease. Comparing patients who had had diabetes for 5 years or less with those who had had the illness for more than 20 years, the frequency of renal insufficiency and of amputations was around 7 times as great in the latter group; for peripheral neuropathy, it was 2 times as great, and for stroke 1.6 times as great. Conclusions. These results show the need to improve the quality of care for diabetic patients in Latin America and the Caribbean, and that QUALIDIAB could help do this. Expanding the QUALIDIAB network will help to more accurately diagnose the quality of that care in the Americas, and it will facilitate interventions aimed at optimizing the care. This, in turn, will improve the quality of life of persons who suffer from diabetes as well as diminish the socioeconomic costs of the disease