Post on 14-Jun-2020
Dr. Manuel Botana, PhDEndocrinologist
Hospital Lucus AugustiOn behalf of SERGAS (Galician Health Service)
Spain
Caroline CostongsEuroHealthNet Deputy Director
Galician Diabetes Experiences
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Galician Population
• 2,731,406 people
• Life expectancy at birth: 82.6
• 23.6% older than 65
• 13.8% diabetes in global (1 each 3 in older than65)(perhaps more)
• Very dispersedpopulation
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• Three programs / projects:
– DE.DI.PO.: Pharmacy offices / Primary Care program for detection of diabetes and health education
– “Xente con Vida ” (People Alive) Program
– “Plan para a Asistencia Integral da Diabetes” –PAI Diabetes- (Plan for Comprehensive Care of Diabetes)
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DE.DI.PO.
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DE.DI.PO
Goals
• Detect in Community Pharmacies, using the test FINDRISC, people with high risk / very high for diabetes or impaired metabolism of carbohydrates
• An intervention of health education in all participants to reduce their risk factors
• Possible diagnosed patients were referred from community pharmacy to their Primary Health Center for confirming health status.
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DE.DI.PO.
Study Population
• Users of pharmacy older than 18, not diagnosed with diabetes, who have SERGAS coverage and accept testing.
Exclusion Criteria :
• Under 18
• Over 18 who are not able to complete the questionnaire
• Patients diagnosed with diabetes mellitus and/or are on diabetes treatment
• Users who do not have SERGAS coverage
• Users who reject to participate in the program
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DE.DI.PO.
• Sociodemographic data collection
• Weight and height measurement
• BMI = weight (kg) / height2
(m2)
• Waist circumference
• Findrisk questionnaire (determines risk for DM)(adapted)
• Capillary blood glucose measurement
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DE.DI.PO.
Results
• 4,578 people accepted to participate (90,1% acceptance)
• 4,222 included
• 384 (9,1%) derived to his primary care doctor
• 5,3% had unknown diabetes (according to previouslypublished data)
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Xente con Vida(People Alive)
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P.A.I. Diabetes(Plan for Comprehensive
Care of Diabetes)
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It is based on four aspects:
• Focused on the patient: give continuity of care and provide a homogeneous attention , regardless of the center and responsible professional any time.
• Ensuring a good clinical practice .• Involving all professionals who are part of diabetes care: doctors,
nurses, pharmacists, etc.• Setting an information and evaluation system to a constant
improvement process
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For these objectives is fundamental the software for Electronic Clinical Records fully implemented in Galicia and almost modified to last version which is foused in process:
– ECR is oriented to the disease and this drives a continuous so all events related with the disease are recorded in a time line process.
– All health professionals in SERGAS with access to ECR can obtain all the information recorded because the ECR is unique for all health centers.
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Establish :• Distribution of tasks• Referral criteria• Agile Communication (IANUS, telemedicine, etc.)
• minimize clinical variability and eliminate duplication of diagnostic and therapeutic procedures
• implementing recommendations contained in guidelines and clinical practice pathways
• ensure fairness, accessibility, continuity, quality and safety of care for all and by prioritizing according to clinical criteria.
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ComprehensiveExtensiveExhaustive
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Screening
Diagnosis
Prevention
Classification
Therapeutic Plan
Hospital Level
Stabilized patient monitoring
Evidence based
Definition of theProcess
Flowchart of theProcess
Flowchart for earlydetection and diagnosis
Phases of theprocess
Evaluation and improvementsystem
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Screening
Diagnosis
Prevention
Classification
Therapeutic Plan
Hospital Level
Stabilized patient monitoring
Evidence based
Definition of theProcess
Flowchart of theProcess
Flowchart for earlydetection and diagnosis
Phases of theprocess
Evaluation and improvementsystem
Annexes with tables for diabetes education, data of various types, social assessment scales, etc.
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The Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS)*
* This presentation arises from the Joint Action addressing chronic diseases and healthy ageing across the life cycle (JA-CHRODIS), which has received funding from the European Union, under the framework of the Health Programme (2008-2013).Sole responsibility lies with the author and the Consumers, Health, Agriculture and Food Executive Agency is not responsiblefor any use that may be made of in the information contained therein.