Individualising Chronic Care Management by Analysing Patients' Needs - A Mixed Method Approach.

BACKGROUND: Modern health systems are increasingly faced with the challenge to provide effective, affordable and accessible health care for people with chronic conditions. As evidence on the specific unmet needs and their impact on health outcomes is limited, practical research is needed to tailor chronic care to individual needs of patients with diabetes. Qualitative approaches to describe professional and informal caregiving will support understanding the complexity of chronic care. Results are intended to provide practical recommendations to be used for systematic implementation of sustainable chronic care models. METHOD: A mixed method study was conducted. A standardised survey (n = 92) of experts in chronic care using mail responses to open-ended questions was conducted to analyse existing chronic care programs focusing on effective, problematic and missing components. An expert workshop (n = 22) of professionals and scientists of a European funded research project MANAGE CARE was used to define a limited number of unmet needs and priorities of elderly patients with type 2 diabetes mellitus and comorbidities. This list was validated and ranked using a multilingual online survey (n = 650). Participants of the online survey included patients, health care professionals and other stakeholders from 56 countries. RESULTS: The survey indicated that current care models need to be improved in terms of financial support, case management and the consideration of social care. The expert workshop identified 150 patient needs which were summarised in 13 needs dimensions. The online survey of these pre-defined dimensions revealed that financial issues, education of both patients and professionals, availability of services as well as health promotion are the most important unmet needs for both patients and professionals. CONCLUSION: The study uncovered competing demands which are not limited to medical conditions. The findings emphasise that future care models need to focus stronger on individual patient needs and promote their active involvement in co-design and implementation. Future research is needed to develop new chronic care models providing evidence-based and practical implications for the regional care setting.

Assessment of incretins in oral glucose and lipid tolerance tests may be indicative in the diagnosis of metabolic syndrome aggravation.

Incretins stimulated by oral meals are claimed to be protective for the pancreatic beta cells, to increase insulin secretion, to inhibit glucagon release, slow gastric emptying (glucagon-like peptide-1) and suppress appetite. Recently it has however been suggested that glucagon-like peptide-1 (GLP-1) is putative early biomarker of metabolic consequences of the obesity associated proinflammatory state. The study was aimed to compare the release of incretins and some of early markers of inflammation at the fasting and postprandial period induced by functional oral glucose as well as lipid load in healthy controls and patients with metabolic syndrome (MS) to see if functional tests may be helpful in searching for the inflammatory status of patients. Fifty patients with MS and 20 healthy volunteers (C) participated in this study. The 3-hour oral glucose (OGTT) and the 8-hour oral lipid (OLTT) tolerance tests were performed. At fasting leptin and adiponectin, as well as every 30 minutes of OGTT and every 2 hours of OLTT blood concentration of GLP-1, glucose-dependent insulinotropic polypeptide (GIP), glucose, insulin, triglycerides, free fatty acids, glutathione peroxidase, interleukin-6, sE-selectin, monocyte chemoattractant protein-1 (MCP1) and visfatin were measured. At fasting and during both OGTT and OLTT the level of incretins did not differ between the MS and the C group. Both glucose and lipids reach food activated incretins secretion. Glucose was the main GLP-1 release activator, while the lipid load activated evidently GIP secretion. A significantly larger AUC-GIP after the lipid-rich meal over the carbohydrate meal was observed, while statistically bigger value of AUC-GLP-1 was noticed in OGTT than in OLTT (P < 0.001) within each of the investigated groups. In patients with the highest fasting plasma GIP concentration (3(rd) tertile), IL-6, MCP-1, sE-selectin and visfatin blood levels were increased and correlated with glutathione peroxydase, leptin/adiponectin ratio, higher visfatin and interleukin-6 levels. The fat containing meals stimulate the long-lasting release of incretins, mainly GIP, parallel to the increase of the markers of low grade inflammation associating obesity in metabolic syndrome. The possibility of use of the postprandial (OLTT) GIP release measurement for the low grade inflammation progress in MS patients is suggested.

Take action to prevent diabetes--the IMAGE toolkit for the prevention of type 2 diabetes in Europe.

When we ask people what they value most, health is usually top of the list. While effective care is available for many chronic diseases, the fact remains that for the patient, the tax payer and the whole of society: prevention is better than cure. Diabetes and its complications are a serious threat to the survival and well-being of an increasing number of people. It is predicted that one in ten Europeans aged 20-79 will have developed diabetes by 2030. Once a disease of old age, diabetes is now common among adults of all ages and is beginning to affect adolescents and even children. Diabetes accounts for up to 18 % of total healthcare expenditure in Europe. The good news is that diabetes is preventable. Compelling evidence shows that the onset of diabetes can be prevented or delayed greatly in individuals at high risk (people with impaired glucose regulation). Clinical research has shown a reduction in risk of developing diabetes of over 50 % following relatively modest changes in lifestyle that include adopting a healthy diet, increasing physical activity, and maintaining a healthy body weight. These results have since been reproduced in real-world prevention programmes. Even a delay of a few years in the progression to diabetes is expected to reduce diabetes-related complications, such as heart, kidney and eye disease and, consequently, to reduce the cost to society. A comprehensive approach to diabetes prevention should combine population based primary prevention with programmes targeted at those who are at high risk. This approach should take account of the local circumstances and diversity within modern society (e.g. social inequalities). The challenge goes beyond the healthcare system. We need to encourage collaboration across many different sectors: education providers, non-governmental organisations, the food industry, the media, urban planners and politicians all have a very important role to play. Small changes in lifestyle will bring big changes in health. Through joint efforts, more people will be reached. The time to act is now.

A European evidence-based guideline for the prevention of type 2 diabetes.

BACKGROUND: The prevalence and socioeconomic burden of type 2 diabetes (T2DM) and associated co-morbidities are rising worldwide. AIMS: This guideline provides evidence-based recommendations for preventing T2DM. METHODS: A European multidisciplinary consortium systematically reviewed the evidence on the effectiveness of screening and interventions for T2DM prevention using SIGN criteria. RESULTS: Obesity and sedentary lifestyle are the main modifiable risk factors. Age and ethnicity are non-modifiable risk factors. Case-finding should follow a step-wise procedure using risk questionnaires and oral glucose tolerance testing. Persons with impaired glucose tolerance and/or fasting glucose are at high-risk and should be prioritized for intensive intervention. Interventions supporting lifestyle changes delay the onset of T2DM in high-risk adults (number-needed-to-treat: 6.4 over 1.8-4.6 years). These should be supported by inter-sectoral strategies that create health promoting environments. Sustained body weight reduction by >or= 5 % lowers risk. Currently metformin, acarbose and orlistat can be considered as second-line prevention options. The population approach should use organized measures to raise awareness and change lifestyle with specific approaches for adolescents, minorities and disadvantaged people. Interventions promoting lifestyle changes are more effective if they target both diet and physical activity, mobilize social support, involve the planned use of established behaviour change techniques, and provide frequent contacts. Cost-effectiveness analysis should take a societal perspective. CONCLUSIONS: Prevention using lifestyle modifications in high-risk individuals is cost-effective and should be embedded in evaluated models of care. Effective prevention plans are predicated upon sustained government initiatives comprising advocacy, community support, fiscal and legislative changes, private sector engagement and continuous media communication.

Quality indicators for the prevention of type 2 diabetes in Europe--IMAGE.

BACKGROUND: The marked increase of type 2 diabetes necessitates active development and implementation of efficient prevention programs. A European level action has been taken by launching the IMAGE project to unify and improve the various prevention management concepts, which currently exist within the EU. This report describes the background and the methods used in the development of the IMAGE project quality indicators for diabetes primary prevention programs. It is targeted to the persons responsible for diabetes prevention at different levels of the health care systems. METHODS: Development of the quality indicators was conducted by a group of specialists representing different professional groups from several European countries. Indicators and measurement recommendations were produced by the expert group in consensus meetings and further developed by combining evidence and expert opinion. RESULTS: The quality indicators were developed for different prevention strategies: population level prevention strategy, screening for high risk, and high risk prevention strategy. Totally, 22 quality indicators were generated. They constitute the minimum level of quality assurance recommended for diabetes prevention programs. In addition, 20 scientific evaluation indicators with measurement standards were produced. These micro level indicators describe measurements, which should be used if evaluation, reporting, and scientific analysis are planned. CONCLUSIONS: We hope that these quality tools together with the IMAGE guidelines will provide a useful tool for improving the quality of diabetes prevention in Europe and make different prevention approaches comparable.

[The efficacy of non-pharmacological intervention in obese patients with newly diagnosed diabetes mellitus type II]. / Skutecznosc interwencji niefarmakologicznej u chorych z nowo rozpoznana cukrzyca typu 2 i towarzyszaca otyloscia.

In Poland like in other countries we observe an increasing number of diabetes mellitus cases with about half of the patients in whom the disease remains undiagnosed. Therefore it seems necessary to improve early diagnoses and prevention of the disease. The aim of the study was to assess the efficiency of a 3-month non-pharmacological intervention based on diet and increased physical activity in patients with newly diagnosed diabetes type 2 (diagnosis based on oral glucose tolerance test (OGTT), WHO 1999). We investigated 37 newly diagnosed diabetic type 2 patients, 16 men (aged 52.4 +/- 5.4) and 21 women (aged 51.0 +/- 5.7). Anthropometric and biochemical measurements were performed before and after intervention. Two-kilometres Walking Test with an intermediate estimation of VO2max and fitness index (FI) was performed before and after intervention. Total abdominal fat volume (measured from diaphragm to pubis): visceral fat volume (VFV) and subcutaneous fat volume (SFV) (mm3) were assessed according to the standard protocol of NMR abdominal examination. Patients completed 12 weeks of supervised intervention focused on weight reduction, increase of physical activity, changes of nutritional habits. Students t-test, Mann-Whitney test and Spearman's correlation were used for statistical analysis. In women the average weight reduction was 4.7 kg (5.8% of initial body weight), whereas in men 5.9 kg (5.9% of initial body weight). In women VO2 max increased from 23.7 +/- 6.4 to 24.9 +/- 4.8 (ns), and fitness index increased from 78.7 +/- 11.7 to 83 +/- 14.7 (ns). In men VO2 max increased from 22.5 +/- 6.7 to 26.6 +/- 8.6 (ns) and fitness index increased from 55.1 +/- 12.5 to 64.8 +/- 13.7 (p < 0.05). In women the level of fasting glycaemia decreased from 6.47 +/- 1.2 to 4.84 mmol/l +/- 0.6 (p < 0.01) and the level of glycaemia at 120 minutes of OGTT decreased from 13.2 +/- 2.5 to 6.76 +/- 2.7 mmol/l (p < 0.01). The decrease of plasma glucose was accompanied by the decrease of fasting insulin from 19.2 +/- 15.5 to 8.53 +/- 93.2 uj/ml (p < 0.01) and in 120 minutes of OGTT from 148.8 +/- 86.2 to 58.4 +/- 41.0 uj/ml (p < 0.01). In men the level of fasting glycaemia decreased from 8.63 +/- 2.0 to 7.07 mmol/l +/- 2.4 (p < 0.05) and the level of glycaemia at 120 minutes of OGTT decreased from 15.76 +/- 3.2 do 9.3 +/- 5.7 mmol/l (p < 0.01). The decrease of plasma glucose was accompanied by the decrease of fasting insulin from 21.99 +/- 12.6 to 10.1 (3.8 uj/ml (p < 0.05) and at 120 minutes of DGTT from 81.5 +/- 52.7 do 41.6 +/- 21.0 uj/ml (p < 0.05). After the intervention 45% of the patients (57% of women and 31% of men) were non-diabetic (correct OGTT). In men visceral fat volume (VFV) was greater than in women (7642.6 +/- 1774.6 and 4789.9 +/- 1242.0 mm3 respectively (p < 0.01). Subcutaneous fat volume (SFV) was smaller in men than in women (7116.5 +/- 2048.5), in men and 10533.9 +/- 3478.3 respectively (p < 0.01). In women and men a strong (p < 0.01) correlation between waist circumference and visceral fat volume (VFV) (r = 0.573 (p < 0.01) and r = 0.833 (p < 0.01) respectively) and subcutaneous fat volume (SFV) (r = 0.900 (p < 0.01) and r = 0.790 (p < 0.01) respectively) was found. The results of the study confirm that in newly diagnosed diabetic type 2 patients body weight reduction and increased physical activity result in the improvement of biochemical indices. In about one half of patients the early phase of the disease might be reversible due to weight reduction and increased physical activity. The non-pharmacological intervention should be the first intervention undertaken in newly diagnosed diabetic type 2 patients.