Diabetes mellitus, an increasing problem
The prevalence of diabetes mellitus is
increasing worldwide. The World
Health Organization (WHO) calculates that there were over 177
million diabetics in 2003. Some researchers expect this number
to have doubled by 2030.
The huge prevalence
of adiposity as well as increased life expectancy in
western industrialized countries is why Type 2 diabetes in
particular has become a more and more common disease.
According to the International Diabetes Federation (IDF),
about
5.5 % of the European population already lives with this
chronic metabolic disease and is aware of it. The number of
those who are unaware of their undiagnosed disease is almost
as high.
One respective cause for this fact is the
abstinence of symptoms during the early aetiopathogenesis of Type
2 diabetes.
The
American Diabetes Association defines Type
2 diabetes as a condition ranging from ‘predominantly insulin
resistance with relative insulin deficiency to predominantly
an insulin secretory defect with insulin resistance.’
However the disease is a continuing
process, which usually precedes a phase of Impaired Glucose
Tolerance (IGT) and/or impaired fasting glucose (IFG).
A
study of the
German Diabetes Centre (GDC)
together with the GSF-National Research Centre for
Environment and Health has shown that more than 16%
of 55-74 year olds have an impaired glucose tolerance.
Since the stadium of an IGT is already associated with an
elevated risk of developing a macroangiopathy, the prevalence
of an IGT can be classified as a disease rather than as a
preliminary phase of a condition.
Thus, nearly every sixth European citizen
lives with the still incurable metabolic syndrome or is at
least in danger of getting diabetes mellitus.
The costs of Diabetes mellitus
The treatment of diabetes is expensive and
an immense burden for health systems – not just in the
European Union.
In the year 1998 the Code-2® study,
which was conducted in eight European countries, revealed
that the total costs of Type 2 diabetes – as a proportion of
the overall healthcare expenditure – ranged between 3% and 6%.
Apart from the fact that costs for Type 1 diabetes are
excluded from this calculation, it is assumed that the real
costs will be even higher since the estimated number of
unknown cases was not part of this calculation. In the USA,
direct costs of diabetes care alone were estimated to have
amounted to 15% of the national overall healthcare expenditure
in 2002.
Moreover, the Code-2® study
identified the distribution of costs. The governmental and
private health insurance companies with 61% had to sustain the
biggest part of total diabetes costs. The following figure
shows a common distribution of costs covered by insurance
companies in Germany.
-Dateien/image002.jpg)
Fig. 1:
Total
GMI costs of Type 2 diabetics in Germany – by category
of costs.
(Source:
Liebl, A., Neiß, A., Spannheimer, A., Reitberger, U., Wagner,
T. & Görtz, A., 2001, p. 587)
In particular, the costs of in-patient
care resulting from complications in Type 2 diabetes are
extremely high.
The study showed that the presence of micro and macro vascular
complications increased the costs per patient more than
threefold. Hospitalization accounted for between 30% and 65%
of total costs. Thus, new strategies and interventions, which
anticipate complications resulting from diabetes, are
required.
It is assumed that the
general risk of a type
2 diabetes patient
to develop a major complication is:
-
43% to
develop a Cardiovascular
Complication
-
23% to
develop a Diabetic Neuropathy
-
11% to
develop a Diabetic Retinopathy
-
6% to develop
a Sophisticated Nephropathy
Furthermore, late effects of diabetes are
always associated with a higher mortality.
As described, the major part of the costs
are not incurred by the necessity to treat and stabilise the
metabolism of glucose and other risk
parameters throughout a patients life but arise
instead from the very high costs of intensive care of late
effects resulting from the disease.
Diabetes mellitus, a challenge for doctors
and patients
Thus, efficient interventions, which avoid
typical after effects or at least delay the individual
aetiopathology, are sensible from the medical and the
economic point of view. Under these circumstances,
three kinds
of interventions can be differentiated:
-
Primary prevention:
Activities designed to prevent
substance abuse before any signs of a problem appear.
-
Measures for a more early diagnosis:
Timely treatment of diabetes
is very important for the prospective course of the disease
and the prevention of complications.
Yet, quite often diabetes is not identified before typical
after effects arise. Diabetes research showed that there are
approximately as many diagnosed as undiagnosed diabetics in
Europe.
-
Secondary prevention
measures:
To reduce the risk of
typical complications, optimal control of blood glucose and
the consequent treatment of further risk factors such
as hypertension or hyperlipoproteinemia
are essential. To achieve this, the consequent
co-operation and compliance of patients, is very important.
The doctor-patient-relationship, confidence, and efficient
teamwork are the basic requirements for successful long-term
treatment.
As a medical tool
for doctors and patients,
computer-assisted
diabetes management
systems
(CDMS) want to improve the health and
quality of life of
diabetes patients by supporting measures, which
normalise the metabolism in the long term.
In recent years, many improvements have
been made in the field of CDMS. On the one hand, software
programmes have become more and more user-friendly. On the
other hand, the scope of programmes has grown rapidly.
Furthermore, growing telematic infrastructure with electronic
and personal health records, standardised data coding and
message transfer concepts (like HL7, UCUM, LOINC etc.) will
enable electronic data documentation and exchange more
efficiently.
In the context of Disease Management
Programmes for diabetes and other chronic diseases, there are
huge expectations in the ‘new technology’. Computer-assisted
diabetes management systems (CDMS)
are used in outpatient care to
rationalise workflows, implement care guidelines, calculate
and illustrate risks, improve doctor-patient-communication and
increase patient compliance. Figure 2 shows a concept of a
CDMS.
-Dateien/image004.gif)
Fig. 2:
Concept of an evidence based CDMS in
outpatient care
(Source:
illustration
according to
Berger, 2004 , IT-unterstütztes Disease Management am
Beispiel „Koranare Herzrankheit“ – Konzeption eines
Risikoevaluierungsmodells und Analyse der praktischen
Umsetzung, diploma thesis, University of Leipzig)
Computer-assisted management systems are
tools − in the concept of national disease management
programmes − aimed at creating the practical interface between
doctor and patient. With the implementation of nationwide
disease management programmes, especially in the European
Union, a further reform of health systems is expected in the
future.
In Germany, for example, the legal basis was provided in 2001
when the match of disease management programmes and the
so-called ‘Risikostrukturausgleich’ (RSA) was legally
established. It regulates payments within the German health
insurance system.
Still, many questions persist which are or
should be of general political, economic, public and thus also
of scientific interest. Does the implementation of such
instruments really result in positive effects on
health outcomes,
the
doctor-patient-relationship or in
improved
compliance? Furthermore, new
areas of applications for computer-assisted systems as part of
disease management control are imaginable.
For example, adapted systems could be used for the early
recognition and prevention for high-risk populations.
