Development Programme for the Prevention 2000–2010 · type 1 diabetes and type 2 diabetes. The...
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Transcript of Development Programme for the Prevention 2000–2010 · type 1 diabetes and type 2 diabetes. The...
2000–2010
DevelopmentProgrammefor the Preventionand Care ofDiabetes in Finland
Tampere 2001
DIABETES CENTRE
DEHKO - Development Programme for the Prevention and Care of Diabetes 2000–2010
Published by Finnish Diabetes Association 2001ISBN 952-5301-13-3Layout by Aino MyllyluomaGummerus Printing, Jyväskylä, Finland 2001
The Finnish Diabetes Association would like to thank the Ministry of SocialAffairs and Health, Finland, and Novo Nordisk A/S, Denmark, for theirgenerous support for the publication of the National Diabetes Programmeof Finland in English. Although the Finnish model is one of many in the fieldof diabetes, it will hopefully provide useful ideas also for other countries.
FOREWORD
iabetes is a growing public-health problem both in Finland and throughout theworld. There is clearly room for improvement in the prevention of diabetes, its carepractices and organization, as well as health outcomes.
In Finland, it has been estimated that 180,000 people have diabetes. Accordingto current estimates, there will be over 300,000 people suffering from diabetes by the year 2010.This is mainly due to genetic factors and the increasing average age of the population. In addi-tion, overweight and physical inactivity make people more susceptible to developing diabetes.Both diabetes and cardiovascular diseases can be decisively reduced through changes in lifestyle.
Although diabetes care in Finland is of a relatively high international standard, there is stilla long way to go to achieve the goals set for care. In many people, diabetes is poorly or verypoorly controlled. The care practices, care organization and health outcomes of diabetes shouldtherefore be considerably improved in Finland.
The Development Programme for the Prevention and Care of Diabetes (DEHKO), drawnup under the coordination of the Finnish Diabetes Association, is a welcome initiative. A largenumber of researchers, experts, clinicians and other professionals practising in the field, as wellas people with diabetes themselves, have participated in the preparatory work of the programme.The programme is ambitious and wide ranging, but the high prevalence of the disease and itsimpact on both public health and the national economy argue for such a multifaceted approach.In municipalities and health-care units, the programme will help to invigorate and strengthenplanning work as well as implementation and follow-up measures concerning diabetes preven-tion and care.
The focal point of the programme is the improvement of care, whereas the strategy relat-ing to the prevention of diabetes and the programme for future measures requires further elabo-ration. In developing the population strategy of prevention, there is reason to take into accountall previous experience, other stakeholders and the Health for All in the 21st Century pro-gramme that is currently under construction. The Target and Action Plan for Social Welfare andHealth Care, which was approved by the Finnish Government in 1999, includes major activitiesrelating to DEHKO, particularly with regard to diabetes education for health-care professionals,quality management and the evaluation of effectiveness. In the high-risk strategy for diabetes,practical forms of cooperation should be set up with the Action Plan for Promoting FinnishHeart Health.
I wish to thank those who have participated in the development of the programme and inparticular the Finnish Diabetes Association for its large-scale preparatory work. It is my hopethat the current consensus and cooperation, which has been so fruitful, will continue to expandto cover all the different players, both in the public sector and the business community, as well aswithin organizations whose contribution is essential to the improvement of the prevention andcare of diabetes.
22 March 2000Eva BiaudetMinister of Health and Social Services
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Development Programme for thePrevention and Treatment of
Diabetes (DEHKO)
Coordination Committee
Chairperson: Professor Marja-Riitta Taskinen
Secretaries: Ms Leena Etu-Seppälä, Secretary General of DEHKO
Ms Keiju Pääskynkivi, Secretary of DEHKO
Members:
Professor Matti Uusitupa (Care Organization and Resources Working Group)
Dr Tero Kangas (Diabetes Cost Working Group, St Vincent Liaison)
Ms Tuula Lehto, Organization Manager (The Role of a Person with Diabetes Working Group)
Dr Pirjo Ilanne-Parikka, Internist (Education Working Group)
Professor Hannele Yki-Järvinen (Type 2 Diabetes Working Group)
Professor Jaakko Tuomilehto (Prevention of Type 2 Diabetes Working Group)
Professor Olli Simell (Type 1 Diabetes Working Group)
Professor Sirkka Keinänen-Kiukaanniemi (Diabetes Registries Working Group)
Dr Timo Kohvakka, Medical Director (Lappeenranta Health Care Centre)
Dr Jouko Saramies, Medical Director (Savitaipale Health Care Centre)
Ms Ammi Isokallio, Department Manager (Chairperson of the Finnish Diabetes Association)
Ms Marjatta Stenius-Kaukonen, Member of Parliament (II Vice-Chairperson of the FinnishDiabetes Association)
Professor Mikael Knip (Chairperson of the Medical Advisory Board of the Finnish DiabetesAssociation)
Mr Jorma Huttunen, Managing Director (Finnish Diabetes Association)
Dr Seppo A Salo, Chief Physician (Finnish Diabetes Association)
Ms Tarja Sampo, Communications Manager (Finnish Diabetes Association)
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Table of Contents
1. TO DECISION MAKERS AND HEALTH-CARE PROVIDERS ........................................................... 7
2. OBJECTIVES, IMPLEMENTATION AND ASSESSMENT OF THE PROGRAMME ...................... 10
3. HISTORY OF DIABETES CARE ARRANGEMENTS IN FINLAND ................................................ 12
4. ORGANIZATION AND RESOURCES OF DIABETES CARE ......................................................... 13
5. COSTS OF DIABETES ................................................................................................................................ 17
6. CARE: A PART OF LIFE FOR A PERSON WITH DIABETES ............................................................ 22
7. LIFESTYLE MODIFICATION IN THE PREVENTION AND CARE OF DIABETES .................... 24
8. EDUCATION ................................................................................................................................................ 28
9. TYPE 2 DIABETES ........................................................................................................................................ 30
10. PREVENTION OF TYPE 2 DIABETES .................................................................................................... 38
11. TYPE 1 DIABETES ........................................................................................................................................ 41
12. COMPLICATIONS OF DIABETES .......................................................................................................... 45
13. DIABETES AND PREGNANCY ............................................................................................................... 51
14. QUALITY IMPROVEMENT AND DIABETES REGISTRIES ............................................................... 54
15. RECOMMENDATIONS FOR ACTION .................................................................................................. 57
16. COMPOSITIONS OF THE WORKING GROUPS ............................................................................... 62
17. APPENDIXES ................................................................................................................................................. 64
18. REFERENCES ................................................................................................................................................. 89
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1. TO DECISION MAKERS ANDHEALTH-CARE PROVIDERS
iabetes is a rapidly expanding pub-lic-health problem both in Finlandand throughout the world. The dis-ease is divided into two main types,
type 1 diabetes and type 2 diabetes. The factorcommon to both types of diabetes is hypergly-cemia and its subsequent harmful effects.Nonetheless, according to current medical un-derstanding, they are clearly two different dis-eases. Both types of diabetes carry a high riskof serious complications.
Diabetes Is Becoming IncreasinglyCommon Throughout the World
The number of people with diabetes is grow-ing fast. Currently, there are more than 150million people with diabetes in the world, andit has been estimated that the number will riseto 300 million by the year 2025.
Nearly 90 per cent of people with diabe-tes suffer from type 2 diabetes, and this groupis rapidly increasing internationally. Althoughthe increase in diabetes is most prominent indeveloping countries, the disease is also be-coming more prevalent in Europe and theNordic countries.
There are approximately 180,000 peoplewith diabetes in Finland, of whom 150,000have type 2 diabetes and 30,000 type 1 diabe-tes. In addition, the blood glucose of an esti-mated 50,000 people exceeds the limit valuefor diabetes. However, according to a popula-
tion survey, these people have no symptomsand are not aware of having diabetes. Thenew diagnostic criteria of blood glucose (Ta-ble 1, page 8) will increase the need for diabe-tes care.
It is estimated that the number of peo-ple with type 2 diabetes will grow by 70 percent by the year 2010, when the total numberof people with diabetes will exceed 300,000.The most significant reasons for the risingprevalence of the disease are the increasingproportion of overweight people, physical in-activity and changes in the age structure ofthe population.
Since most people with type 2 diabetesare treated within primary health care, thisdisease is a major problem for primary healthcare. An intolerable problem for society canonly be averted through efforts to prevent thedisease and its complications.
The incidence of type 1 diabetes in Fin-land is the highest in the world, and it is in-creasing at an approximate rate of two percent per year. Although the number of peoplewith type 1 diabetes is considerably smallerthan that of people with type 2 diabetes, itsincreasing incidence in small children, thelong duration of the disease and the early oc-currence of complications caused by poor caremake type 1 diabetes a heavy burden for theindividual and a major challenge for healthcare.
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The Standard of Diabetes Care inFinland Is Unsatisfactory
Even though diabetes care in Finland is of arelatively high international standard, there isstill a long way to go to achieve the desiredgoals. The study by Valle et al which recentlyassessed the success of diabetes care in Fin-land demonstrated that only one-fourth ofpeople with type 1 diabetes have optimal glyc-emic control, whereas approximately 50 percent of them have unsatisfactory or alarminglypoor glycemic control. The figures are evenbleaker with regard to people with type 2 dia-betes: only 10 per cent have optimal glycemiccontrol. The critical question here is why dia-betes care has been unsuccessful.
With patient education, self-monitoringand adequate insulin treatment, it is possibletoday to maintain the blood glucose of peoplewith type 1 diabetes at a relatively normal lev-el, even in varying circumstances. With type 2diabetes, the treatment of hyperglycemia isproblematic because of the limited efficacy ofthe medicinal products in use.
Finnish people with type 2 diabetes ad-ditionally have very poor control of the mostsignificant risk factors for cardiovascular dis-ease, ie blood lipids and blood pressure. The
modest outcome of treatment is also partiallydue to the poor execution of non-pharmaco-logical therapy.
In the current situation, blood pressureand blood lipid levels are relatively frequentlymonitored, but this does not necessarily leadto further measures. Because effective andwell-tolerated medications are available, care-ful treatment of hypertension and elevatedblood lipid levels is a challenge to the primaryhealth-care system. Similarly, it is worth in-vesting in the treatment of hyperglycemia be-cause its link to the incidence of microvascularcomplications is indisputable. In other words,we have the means to provide high-qualitycare, but the implementation of care fails.
What Is It that Costsin Diabetes Care?
Of all people with diabetes, approximately 75-80 per cent die of cardiovascular diseases. Peo-ple with type 2 diabetes have a two to fourtimes higher risk of coronary heart diseasethan the rest of the population, and theirprognosis is poorer. The risk of cerebrovascu-lar diseases and peripheral vascular disease isalso significantly higher in type 2 diabetes.
Cardiovascular diseases are the main rea-
Table 1.
Diagnostic criteria of blood glucose(mmol/l) fasting and 2 h after a 75 g oral glucose load (WHO 1999)
Plasmavenous
Plasmacapillary
Whole bloodvenous
Whole bloodcapillary
Normal fasting value2 h value
≤ 6.0≤ 7.7
≤ 6.0≤ 8.8
≤ 5.5≤ 6.6
≤ 5.5≤ 7.7
Impaired fastingglucose (IFG)
fasting value2 h value
6.1-6.9< 7.8
6.1-6.9< 8.9
5.6-6.0< 6.7
5.6-6.0< 7.8
Impaired glucosetolerance (IGT)
fasting value2 h value
< 7.07.8-11.0
< 7.08.9-12.1
< 6.16.7-9.9
< 6.17.8-11.0
Diabetes mellitus fasting value2 h value
≥ 7.0≥ 11.1
≥ 7.0≥ 12.2
≥ 6.1≥ 10.0
≥ 6.1≥ 11.1
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son for the high cost of diabetes care. Accord-ing to the study on diabetes costs by Kangas,hospitalization forms the greatest expense, ac-counting for about 56 per cent of the totalcost of diabetes care. Most of the hospital careof diabetes (73%) consists of the treatment ofcardiovascular diseases.
According to current estimates, the costswill quickly increase in the future owing to therapid growth in the numbers of people withtype 2 diabetes. The future reduction of costsnecessitates prompt recognition of the riskfactors of cardiovascular diseases and their ag-gressive treatment.
How Can Diabetes CareBe Improved?
The Development Programme for the Preven-tion and Care of Diabetes (DEHKO) is anall-inclusive programme. Its primary focus ison type 2 diabetes which is the most problem-atic and currently causes the highest costs.DEHKO is not a treatment guideline forhealth-care personnel but a comprehensivedevelopment programme as a basis for practi-cal care.
The main goal of the programme is theprevention of type 2 diabetes. This will be along-term and demanding task, and it is sug-gested that an entirely separate plan be drawnup for the purpose.
The second most important task is toagree upon measures to reduce the risk of car-diovascular disease among people with type 2diabetes. This requires a substantial change ofattitude by the decision makers in the health-care field and the care providers.
The central message is that type 2 diabe-tes is by no means a “mild diabetic disease”but a fatal cardiovascular disease if all the riskfactors are not properly treated.
The care organization has an essential role inimplementing care. The expedient use of ex-isting resources is the first step to be taken inimproving care. The care of people with type 1diabetes in the units of primary health careshould be concentrated under physicians re-sponsible for diabetes care or general practi-tioners who are familiar with diabetes. Type 2diabetes care should be coordinated by a phy-sician responsible for diabetes care and imple-mented by physicians with population-basedresponsibility. A smooth-running diabetesregistry is required for monitoring the qualityof care.
The training of health-care professionalsis an essential part of the implementation ofthe action programme. Personnel with popu-lation-based responsibility have the highestpriority.
The action programme also charts theproblems in the care of type 1 diabetes andproposes means to improve the quality of care.The key objective is to promote self-care byincreasing education and self-care training, aswell as to ensure that individual care needs aremet and necessary specialized services for aperson with diabetes are provided.
An attempt is made through the actionprogramme to reinforce the self-responsibilityof people with diabetes for the success of theircare, as well as their own ways of influencingthe treatment of their disease. This also neces-sitates making better use of the existing serv-ice system and reassessment of the utilizationof the care resources.
Successful implementation of the Devel-opment Programme for the Prevention andCare of Diabetes means enhanced quality ofcare, resulting in a marked improvement inthe quality of life on an individual level and adecrease in the economic burden on a societallevel.
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2. OBJECTIVES, IMPLEMENTATION ANDASSESSMENT OF THE PROGRAMME
Objectives
The Development Programme for the Preven-tion and Care of Diabetes has eight objectivesconcerning the organization of care in 2000-2010:
■ There will be a quality system of diabetescare in each care unit, a natural part of whichis regular and comprehensive diabetes trainingwithin primary health care.
■ Measures aimed at the prevention of type2 diabetes will be a permanent function of pri-mary health care.
■ There will be a computerized diabetes reg-istry in each care unit and in each district, aswell as a national diabetes registry.
■ The care organization for people with dia-betes will be based on smooth-running carechains, shared responsibility for care betweenprimary health care and specialized medicalcare, and flexible consultation practices.
■ Each person with type 1 diabetes will haveaccess to individual, high-quality self-care.
■ All people with type 2 diabetes will receivesufficient education in self-care, and their car-diovascular risk factors will be treated alongwith their hyperglycemia.
■ People with diabetes will have the skill re-quired for self-care and have a high level ofsatisfaction with their care.
■ The cooperation between the health-caresystem and the diabetes associations in sup-
porting self-care will become established as apermanent form of activity.
The objectives concerning health outcomestargeted for 2010 are as follows:
■ The glycemic control of people with dia-betes will have improved so that at least 50per cent of both people with type 1 and type 2diabetes have optimal glycemic control, andno more than 30 per cent have unsatisfactoryand 20 per cent poor glycemic control.
■ The incidence of cardiovascular diseaseamong people with diabetes will drop by atleast one-third.
■ The complications related to diabetes willdecrease according to the objectives of the Eu-ropean St Vincent Programme:
• leg amputations at least by half• diabetic retinopathy at least by one-third• diabetic nephropathy at least by one-third.
Implementation
The Finnish Diabetes Association will act ascoordinator of the first part (1998-2002) ofthe Development Programme for the Preven-tion and Care of Diabetes, to be carried out inthe primary health-care system by means ofan extensive cooperative network.
The most important cooperative part-ners are Finnish diabetes experts, the Ministryof Social Affairs and Health, the Social Insur-ance Institution (KELA), National PublicHealth Institute, the National Research andDevelopment Centre for Welfare and Health(STAKES), the Sub-Committee on Cardio-vascular Diseases and Diabetes of the Adviso-
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ry Board for Public Health, the Association ofFinnish Local and Regional Authorities andthe Finnish Heart Association. The FinnishSlot Machine Association (RAY), pharmaceu-tical companies and the Finnish Diabetes As-sociation are responsible for the funding.
The first part of the programme is de-signed to proceed in three phases. The firstphase focused on preparation of the actionprogramme and its approval in the consensusmeeting held on 19 January 2000. The secondphase consists of publicity, training and mar-keting the action programme. In this phase,the evaluation of the baseline situation con-cerning the care and glycemic control of peo-ple with diabetes will be initiated, as well asthe clarification of the options for creating anational quality monitoring system for diabe-tes care. In the third phase, the preventionprogramme for type 2 diabetes will be startedand further measures will be proposed to carrythe DEHKO action programme forward.
Follow Up and Supervision
The Finnish Diabetes Association will imple-ment the programme in cooperation with de-cision makers and providers of health care.The Finnish Diabetes Association will organ-
ize consultation meetings for follow up, super-vision and assessment, as well as appointingworking groups when necessary.
There will be close cooperation with theFinnish Heart Association and the ActionPlan for Promoting Finnish Heart Health.The Sub-Committee on Cardiovascular Dis-eases and Diabetes of the Advisory Board forPublic Health and the diabetes workinggroups of the various hospital districts will actas the follow-up and supervision teams, whosesupport is essential to the success of the pro-gramme.
Assessment
The implementation and results of the firstpart of the DEHKO action programme areassessed at the end of each phase. At the endof the first part a total assessment of the im-plementation will be conducted, and 8-10years later the effectiveness of the pro-gramme will be assessed in comparison withthe baseline situation. The assessment is par-tially self-conducted and partially an audit byoutside parties. The concepts and methodswill be defined in connection with the firstassessment. The assessment plan is presentedin Appendix 1.
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3. HISTORY OF DIABETES CAREARRANGEMENTS IN FINLAND
iabetes care has been systematicallydeveloped in Finland for more thantwo decades. When the Sickness In-surance Act came into force in 1963,
the preconditions of care were improved, but itwas specifically the Mobile Clinic Research Pro-gramme conducted at the end of the 1960s bythe Social Insurance Institution that raisedawareness about the significance of diabetes as amajor public-health problem. The Governmen-tal Diabetes Committee was formed in 1974 as aresult of an initiative by the Finnish DiabetesAssociation, and the report of the committee(Plan for Organizing Diabetes Care in Finland)was published two years later.
The committee report had a significantimpact on the development of diabetes care:diabetes working groups were founded in hos-pital districts and a national diabetes nursesystem was created. The National Board ofHealth issued guidelines concerning regionalcare provisions for diabetes in 1983. Guide-lines were published in 1985 for the distribu-tion of care supplies and equipment. Most ofthe regional care plans of the hospital districtswere also published in the 1980s.
In 1989, the European St Vincent Pro-gramme for the development of diabetes carewas launched by the International DiabetesFederation (IDF) and the World Health Or-ganization (WHO) (Appendix 2). The Finn-ish Ministry of Social Affairs and Health wascommitted to the implementation of the ob-jectives of the programme and appointed aliaison person to the St Vincent Action Pro-gramme for Finland.
In the autumn of 1991, representativesof the Finnish Diabetes Association, the Min-istry of Social Affairs and Health and the Na-tional Agency for Social Welfare and Health
met to discuss the implementation of the StVincent Programme and the WHO resolu-tions concerning diabetes in Finland. As a re-sult of these discussions, the National Agencyfor Social Welfare and Health in 1992 ap-pointed a special diabetes expert group withthe task of improving diabetes care in Finland.The group was also designated to act as thefollow-up group for the implementation ofthe St Vincent Programme in Finland.
However, due to various reasons, thework of the expert group was interrupted.Only in 1998 was a successor found to contin-ue the work, when the Ministry of Social Af-fairs and Health created the Sub-Committeeon Cardiovascular Diseases and Diabetes un-der the auspices of the Advisory Board forPublic Health. The tasks of the sub-commit-tee consist in monitoring the implementationof the Action Plan for Promoting FinnishHeart Health and the Development Pro-gramme for the Prevention and Care of Dia-betes, as well as making proposals relating tothe prevention of cardiovascular diseases anddiabetes. The group also acts as the officialfollow-up group for the implementation ofthe St Vincent Programme in Finland.
Since the care organization of diabetesin Finland still has its basis in the provisionscreated over 20 years ago, it no longer meetsthe demands of today in many respects. Theseverity of type 2 diabetes and the problemsassociated with the disease were not broughtinto focus until the 1980s and 1990s, requir-ing an entirely new approach. On the otherhand, the on-going great changes and devel-opment projects in the Finnish health-caresystem call for a link to be established be-tween diabetes care and the current reality ofthe health-care field as a whole.
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I
The Role of the Finnish DiabetesAssociation in Improving Care
The Finnish Diabetes Association is one ofthe major public health organizations in Fin-land. The 108 local branches and three pro-fessional member organizations of the Finn-ish Diabetes Association have a total of over56,000 individual members. The national ac-tivities of the Finnish Diabetes Associationare concentrated in the Diabetes Centre,which is located in Tampere, as well as in fiveregional units. Since the end of 1970s, theFinnish Diabetes Association has been ful-filling the duties outlined by the Govern-mental Diabetes Committee and has becomea central agent in improving diabetes care inFinland.
For over 20 years, the Diabetes Centrehas been responsible for the diabetes educa-
tion of nurses, as well as the self-care trainingof people with diabetes.
Since the 1970s, the Finnish DiabetesAssociation has also produced guidance andsupport material for both people with diabetesand health-care professionals, as well as na-tional guidelines and recommendations forcare and treatment.
In order to improve diabetes care and an-alyse the costs, the Finnish Diabetes Associa-tion commissioned the FinnDiab Study whichwas published in 1995.
The current National Diabetes Pro-gramme (Development Programme for thePrevention and Care of Diabetes) will be thefocal area of the Finnish Diabetes Associationfor the next few years. Broad cooperation willtake place with the authorities and health-carepersonnel in both the planning and implemen-tation of the programme.
4. ORGANIZATION ANDRESOURCES OF DIABETES CARE
n Finland, the public health-care system isresponsible for diabetes care, with primaryhealth care bearing the main responsibili-ty. The initial care of adults with type 1
diabetes, the care of children, young peopleand pregnant women with diabetes, as well asthe most severe diabetic complications, are theresponsibility of the specialized medical caresystem.
Problems in the Current Situation
The quality and availability of diabetes carehave not met demands in all respects in recentyears. The adoption of the system of popula-tion-based responsibility in primary healthcare was an important change with regard to
health-care policy and did improve the availa-bility of care in general. With regard to diabe-tes, however, it worsened the situation in someparts of Finland. At the same time, geographi-cal disparities in the availability, organizationand quality of care have increased.
In addition, the recession of the early1990s had an adverse impact on diabetes care,particularly in preventive health care. Manyhealth-care centres had to give up the diabetesnurse system, or it was absorbed into other ac-tivities of primary health care.
There is marked variation in the posi-tion, duties and availability of a diabetes nurse,and some health-care centres have not ap-pointed any physician or nurse to be responsi-ble for diabetes care. At the same time, little
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attention has been paid to the disseminationof information concerning up-to-date diabe-tes care as part of staff training.
The problems are most apparent insmall health-care centres, but they occur evenin the largest units of primary health care. Inaddition to the lack of services offered by adiabetes nurse, many health-care units provideinadequate access to the services of nutrition-ists and podiatrists, as well as poor oral healthcare for people with diabetes.
There are regional differences in the im-plementation and comprehensiveness of thescreening for retinal changes, and in certainregions there are also problems concerning theclarity of the organization of diabetes care.
Regional diabetes working groups cur-rently operate in 16 of the 21 hospital districtsin Finland. There are also diabetes activities inother districts, but in one-fourth of hospitaldistricts there is no party that coordinates re-gional cooperation.
Although the existing diabetes workinggroups function in diverse ways, on the wholethey are quite active. The annual regionaltraining sessions are the most visible form ofactivity, but in many places a great deal ofwork has also been done to develop care coop-eration. Most of the regional diabetes careprogrammes were drafted in the 1980s and aretherefore largely outdated. In the 1990s, onlythree of the hospital districts have eitherdrawn up totally new care programmes or up-dated their former one.
Few health-care units have methodicallyaddressed the quality of diabetes care. Im-provement of care is required in both type 1and type 2 diabetes. Moreover, type 2 diabetesand its prevention should be given special at-tention when making decisions concerninghealth-care.
In some hospital districts, developmentprojects concerning diabetes care have recent-ly been started. Examples include the CareChain of a Person with Diabetes Project inthe Pirkanmaa Hospital District, the KAS-
DIA Project in Kangasala that aims at im-proving the care of type 2 diabetes, a projectfor improving diabetic foot care in EasternFinland and the regional diabetes registryproject in the Kuopio University HospitalDistrict.
The Care Organization
The Public Health Act and the SpecializedMedical Care Act require that the publichealth-care system retain primary responsibil-ity for organizing diabetes care. Occupationalhealth-care and the private sector also have animportant role of their own in the care organi-zation.
In developing care, the principal rule isto improve the cooperation between primaryhealth care and specialized medical care, anappropriate division of labour ( “shared caremodel”) and straightforward consultation op-portunities in both directions.
The diabetic care of children, youngpeople and pregnant women, as well as thetreatment of severe complications, are concen-trated in the specialized medical care system.However, since the primary health-care sys-tem has overall responsibility for the popula-tion in each region, the other forms of basiccare (such as for infections) for these diabeticgroups are generally provided in health-carecentres.
The diabetes working groups of the hos-pital districts have a significant role in the im-provement of regional diabetes care. Thereshould be an appointed diabetes workinggroup in each hospital district. A representa-tive of people with diabetes as well as the dif-ferent professionals should be included in thegroup. It is the duty of the diabetes workinggroup to act as the regional coordinator of di-abetes care and its development, as well as theorganizer of regional training for health-careprofessionals (Appendix 3).
Because the care of people with diabetesrequires cooperation among many different
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players, it is appropriate for the central poli-cies concerning the improvement of diabetescare to be worked out individually in eachhospital district. In addition to quality work,the districts must take into account the shar-ing of the care, the functionality of the carechains, both problem-oriented and client-cen-tred approaches and process thinking.
The role of the Finnish Diabetes Associ-ation in the care organization is further em-phasized in disseminating information, organ-izing training courses for people with diabetesand diabetes education for health-care profes-sionals and publishing (Appendix 4). TheFinnish Diabetes Association also holds theleading position in coordinating and improv-ing the quality of patient education. Its localbranches throughout Finland support the self-care of people with diabetes in cooperationwith health-care centres.
Care of People with Type 1Diabetes in the Primary Health-Care System
Type 1 diabetes is present in all age groups.The care of children and young people, as wellas other special groups of people with diabe-tes, is organized as outlined above. The initialcare of people who are diagnosed with type 1diabetes as adults usually takes place in a cen-tral hospital or in the diabetes outpatient clin-ic or ward of a regional hospital that has theadequate facilities.
The hospital that initiated the care is usu-ally responsible for the care of the patient forone or two years, and the medical staff super-vise and assist the person with diabetes in tak-ing responsibility for his/her self-care and self-monitoring of the disease. When the situationhas stabilized, the goals of initial care have beenreached, and the person with diabetes is capa-ble of taking the main responsibility for his/herown care, he/she can be transferred into theprimary health-care system which must havesufficient facilities for type 1 diabetes care.
The individual with diabetes and the new careunit receive a case summary consisting of thecurrent treatments, the care plan and anyproblems that have arisen during the course ofthe care. Those people with diabetes whosedisease is exceptionally unstable, or who haveserious complications, should continue to betreated primarily within the specialized medi-cal care system.
The care of type 1 diabetes requires con-tinual training of physicians and other person-nel, active consultation with other relevantparties and a sufficient number of patientswith type 1 diabetes in order to maintain ex-perience and current knowledge of the disease.For this reason, these patients may be concen-trated in the care of a physician (as an excep-tion to the system of population-based re-sponsibility) who has at least 20-30 personswith type 1 diabetes in his/her care.
Certain services can be procured fromprivate specialists, who otherwise act primarilyas consultants. The basic services of the publichealth-care system (laboratory, diabetes nurse,distribution of care supplies and equipment)should also be available to those people withdiabetes who are treated by a private physi-cian.
In Finland, several alternative models oforganizing diabetes care must be applied tosufficiently take into account geographical,regional and other differences.
Care of People with Type 2Diabetes in the Primary Health-Care System
As a rule, people with type 2 diabetes aretreated within primary health-care. A physi-cian responsible for diabetes care coordinatesand develops the care, and physicians withpopulation-based responsibility implement it.Special attention is paid to the prevention andearly treatment of cardiovascular disease.
It is also important that physicians andnurses are sufficiently familiar with the princi-
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ples of the prevention and treatment of over-weight and are aware of the problems in thecare of diabetic nephropathy and foot compli-cations. They should also understand the prin-ciples of the prevention of such complicationsand the significance of comprehensive screen-ing for diabetic retinopathy.
The care of people with type 2 diabetesrequires natural and flexible opportunities forconsultations both within the health-care cen-tre in question and with the specialized medi-cal care system. The prevention of type 2 dia-betes is also principally the responsibility ofthe primary health-care system. In prevention,both the population-based responsibility ap-proach and general health education can beutilized.
Occupational health care is a central re-source in risk factor monitoring and the treat-ment of cardiovascular diseases among peoplewith type 2 diabetes. Occupational health careis also an essential part in prevention of diabe-tes.
Resources and Division ofResponsibilities
Improving diabetes care is a necessity in orderto ensure a better quality of life for peoplewith diabetes and for the prevention of costlycomplications. The care organization holds anessential position in improving care. Becausethe resources of the health-care system willalso be limited in the future, reassessment ofcurrent resources is essential at all levels of di-abetes care. The most appropriate use of exist-ing resources possible is the first step in careimprovement.
A sufficient number of specialists work-ing within specialized medical care must beensured in order to organize and further de-velop the care of people with diabetes. Theunits responsible for the care of children withdiabetes must be guaranteed better resourcesthan has been the case to date.
Each health-care unit that treats peoplewith diabetes must have a diabetes team. This
team should include at least a physician re-sponsible for diabetes care (Appendix 5), a di-abetes nurse (Appendix 6), a nutritionist (de-pending on the size of the population, Appen-dix 7) and a podiatrist (Appendix 8). A psy-chologist, a physical therapist or a physical ed-ucation instructor could be included wherenecessary.
This team coordinates diabetes care,evaluates and improves the quality of care andtrains other personnel. The person with diabe-tes is an equal member of the team with re-gard to his/her own care.
In the primary health-care system, thereshould be one full-time diabetes nurse per300-400 diabetic patients and one nutritionistper 30,000 population.
As necessary, the nutritionist participatesin patient education, is responsible for the nu-tritional training of other personnel and is thekey player in the planning of lifestyle counsel-ling.
Currently, there are permanent posts forpodiatrists in only a few health-care units, andtheir number should be increased throughoutthe country in order to secure services for theprevention of foot problems.
Since it is not always possible for theunits of the primary health-care system to ar-range the services of a nutritionist or podia-trist on their own, these services can also beestablished jointly among several health-carecentres or contracted out to private serviceproviders.
The screening for retinal changes shouldbe organized comprehensively using themethod of fundus photography. Organizingregular check-ups of oral health is also the re-sponsibility of the diabetes care unit, whereasthe primary health-care system treats possibleillnesses and conditions.
Improving the Quality of Care
The improvement of the quality of diabetescare must receive attention in all units in bothprimary health care and specialized medical
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DEHKO 2000-2010
care. Establishing a smooth care chain, qualitycriteria for each care unit and a diabetes regis-try provides efficient tools for the improve-ment and assessment of the quality of thecare.
Each unit’s own quality system need notbe complicated. It should consist of a generaldescription of the unit and guidelines for thecare process of a person with diabetes, such as
• resources (staff, etc)• description of activities• accessibility• education• patient satisfaction• glycemic control
TrainingIn the basic and extended training of physi-cians and other care personnel, emphasis is puton increasing knowledge about diabetes.Through diabetes education for health-careprofessionals, know-how on modern diabetescare is ensured at all levels of the health-caresystem. Training should be organized both na-tionally and regionally, with regional trainingensuring that local circumstances are takeninto account.
The diabetes working groups of the hos-pital districts should bear the main responsi-bility for the organization and content of theregional training. Outside sponsorhip is anoption for funding. It is also important thatemployers enable personnel to participate indiabetes education for health-care profession-als by reserving adequate financial allowancesand substitute work staff.
5. COSTS OF DIABETES
iabetes is an expensive disease forsociety. In Finland, the direct costsfor the health care of people withdiabetes were over FIM 5.2 billion
(USD 1.0 billion at the European CentralBank average exchange rate for the year 1997)in 1997, most of which (approximately USD570 million) was spent on hospital and long-term care. According to both Finnish and in-ternational research, the health care of peoplewith diabetes is at least 2.5 times more expen-sive than the health care of age- and gender-matched control populations and about fivetimes as expensive as the average for the entirepopulation.
People with type 2 diabetes are heavyconsumers of health-care services because ofinadequate control of their glucose metabo-
lism and insufficient treatment of their cardi-ovascular risk factors. The costs of the care ofpeople with type 2 diabetes were 88 per centof the total costs of diabetes care and totalledUSD 876 million in 1997, and a significantpart of this was caused by preventable cardio-vascular diseases related to diabetes.
According to recent research, definitesavings can be achieved through correct allo-cation of care, improvement in the productivi-ty of the care organization and investment inthe prevention of type 2 diabetes and its com-plications. As a result of these measures, thehuman suffering of people with diabetes andexpensive hospital care can be reduced, andthe trend in the cost of diabetes care can becorrected.
D
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The Importance of Knowing theCost Structure of Health Care
It is of great importance to be familiar withthe cost structure of diabetes care becausehealth-care costs are rapidly increasing,
whereas economic resources are limited. If thecost structure and the cost-effectiveness ofcare are not properly understood, there is adanger of making savings in the wrong areas(eg distribution of self-care equipment), ieareas that have a decisive impact on reaching
Table 2.
Costs of health care for people with diabetes and their age- and gender-matched controls
(USD * 1000). Helsinki 1997. The length of hospital stay was limited to 365 days/admission.
Type of careType 1diabetes
Type 1controls
Type 2diabetes
Type 2controls
Total fordiabeticpopulation
Total forcontrolpopulation
Excess costscaused bydiabetes
% of totalexcesscosts
Hospital care withdiabetes as aprimary diagnosis
501 0 1108 0 1609 0 1609 3.5
Hospital care ofmacrovascularcomplications
321 19 11879 3940 12200 3959 8241 17.9
Hospital care ofmicrovascularcomplications
865 108 2050 553 2915 661 2254 4.9
Hospital care forillnesses unconnectedto diabetes
1300 671 23260 10719 24560 11390 13170 28.7
Acute hospitalcare, total
2987 798 38297 15212 41284 16010 25274 55.0
Long-terminpatient care
49 239 6359 5937 6408 6176 232 0.5
Acute and long-termhospital care, total
3036 1037 44656 21149 47692 22186 25506 55.6
Outpatient care 2933 589 15541 6926 18474 7515 10959 23.9
Medicines fordiabetes
1533 0 3222 0 4755 0 4755 10.4
Medicines for otherdiseases
1246 334 7032 3786 8278 4120 4158 9.1
Self-careequipment
747 7 1271 44 2018 51 1967 4.3
Travel costs andother compensations
390 236 1876 1765 2266 2001 265 0.6
Total expenditure 9885 2378* 73598 35193* 83483 37571* 45912 100.0
Population (n) 2324 2153 11414 10920 13738 13073 - -
Expenditure/indivi-dual (USD/year)
4253 1105* 6448 3223* 6077 2874* 3203* -
Population receivinghospital care (n)
616 226 4558 2549 5174 2775 2399 -
*The expenditure for missing controls added as an average
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DEHKO 2000-2010
diabetes care objectives but are of minor im-portance with regard to total costs.
The costs caused by diabetes consist ofdirect costs (outpatient and hospital care,medications, self-care equipment and rehabili-tation) and indirect costs (labour and produc-tivity lost because of sick leave, early retire-ment and premature death), as well as psycho-social, or intangible, costs that are difficult tocalculate (for instance the impact of diabeteson quality of life). In the decision-makingprocess within health care, detailed knowledgeof the direct costs of diabetes provides thegreatest benefits.
Research Findings Outlinethe Situation
The direct and indirect costs of diabetes inFinland in 1989 were calculated in connectionwith the FinnDiab Study that was publishedin 1995. The direct costs were USD 298 mil-lion (79% of total costs), and the indirect costswere USD 79 million (21%).
The calculated direct costs of the care ofpeople with diabetes accounted for 5.8 percent of the total costs of health-care in 1989.The total costs of diabetes care were causedoverwhelmingly (81%) by hospital care. How-ever, at the time of study the costs of outpa-tient care could not be comprehensively deter-mined, leading to overestimation of the pro-portion accounted for by hospital care.
The most recent information is based onresearch that investigated the utilization andcosts of diabetes care in the Helsinki HospitalDistrict. On the basis of the results, it hasbeen possible to estimate the costs of the careof people with diabetes for the whole of Fin-land in 1997 while taking background factorsinto account.
The direct costs of the health care ofpeople with diabetes in the entire country(USD 1.0 billion) were 11.0 per cent of thetotal health-care costs in Finland (USD 8.9billion). Correspondingly, the share of hospital
care (USD 570 million) was 6.4 per cent ofthe total costs. The costs were principallycaused by the care of people with type 2 dia-betes. (Table 2)
In Helsinki, the share of type 2 diabetescare was 88 per cent in the total costs of dia-betes care and 94 per cent in the cost of hos-pital inpatient care of diabetes. The number ofhospital inpatient days spent by people withdiabetes was 1.8 times higher than among thecorresponding age groups in general, account-ing for 14.5 per cent of all hospital inpatientdays of somatic care. The costs of diabetes-related hospital care of people with type 2 dia-betes were mainly due to macrovascular com-plications (79%), whereas most of the costs fortype 1 diabetes were related to microvascularcomplications (51%). (Figure 1)
Figure 1.
Distribution of costs of hospital inpatient care fordiabetes and its complications (%).(Diseasesunconnected to diabetes and long-term care arenot included.)
Figure 2 presents the distribution of diabetescosts according to the Helsinki Study. Theshare of outpatient care was 22.1 per cent. In
80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.0
0.0 Diabetes asa PrimaryDiagnosis
Macrovascularcomplications
Type 1Type 2
%
29.7
7.5
19.0
79.1
51.3
13.4
Macrovascularcomplications
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DEHKO 2000-2010
Figure 2.
Distribution of direct health-care costs of diabetes (%).Helsinki in 1997. (Hospital stays were limited to365 days/admission.)
other words, the Helsinki Study was able toevaluate the costs of outpatient care signifi-cantly more comprehensively than theFinnDiab Study. Medication costs were 15.6per cent of the total costs of care. They includ-ed all the medicines used by people with dia-betes, whereas in the 1989 study only medi-cines for diabetes were included. The costshare of self-care equipment was 2.4 per cent.
According to the study, the health-care costsof people with diabetes residing in Helsinkitotalled USD 74 million in 1997, which was12.6 per cent of the final operating expendi-ture of the Helsinki Health Department, al-though it was not possible to calculate thecosts of the dental care, occupational healthcare and mental health care of people with di-abetes. The care costs of people with diabeteswere 2.2 times those of the age- and gender-matched control population.
2.4% 2.7%
49.5%
7.7%
22.1%
15.6%
HospitalCare
Long-termcare
Outpatientcare
MedicationsSelf-careequipment
Travelcosts, etc.
Calculating Cost-Effectiveness
Improvement of care always causes additionalexpenditure. Therefore, when decisions aremade, information is needed not only about thedirect costs of a disease but also about thecost-effectiveness of treatments and otherhealth-care procedures. It is estimated that nomore than 15 per cent of all health-care proce-dures are both life prolonging and cost saving.Thus, there is always a price for the additionalyears of life attributed to the care.
In health-care economics, cost-effectivenessis evaluated by calculating the cost of one life-year saved (LYS) or one additional quality-ad-justed life-year (QALY) achieved by a givenhealth-care procedure. In the case where theprocedure used has no effect whatsoever onquality of life, the cost per LYS and cost perQALY are equal for practical purposes.
In Sweden, a limit value of SEK 200,000 (ap-proximately USD 20,000) is used in decidingwhether an intervention is cost-effective or not.
In the USA, the following limit values have beenused:
• highly cost-effective: less than USD 20,000/LYS or QALY
• relatively cost-effective: USD 20,000-40,000/LYS or QALY
• borderline: USD >40,000-60,000/LYS orQALY
• expensive: USD >60,000-100,000/LYS orQALY
Diabetes Care Is Cost-Effective
Efficacious care in high-risk individuals, suchas people with diabetes, is generally alwayscost-effective regardless of the amount of carecosts. There are several areas in diabetes carewhere cost-effectiveness is particularly evi-dent:
1. Prevention of cardiovascular diseasesamong people with type 2 diabetes. In the
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DEHKO 2000-2010
Hos
pita
l day
s/10
0 pa
tient
yea
rs
Healthy IFG Diabetes
UKPDS Study, the cost of one life-yearsaved by lowering blood pressure was atmost only GBP 720.
2. In the Nordic 4S Study, the cost of onelife-year saved by lowering the blood cho-lesterol of Finnish people with diabeteswas USD 2,524, which is clearly cost-effective. The procedure was much lesscost-effective in people without diabetes(USD 8,201/LYS). Figure 3 demonstrateshow in the 4S Study the effect was espe-cially reflected in a reduction in hospitalinpatient days of people with diabetes.
3. The use of aspirin to prevent myocardialinfarction and stroke has also proven to beeffective. In terms of cost-effectiveness, itcan be cost saving and is at least cost-neu-tral (at most USD 0/LYS).
4. The prevention and early detection ofboth diabetic retinopathy and diabetic ne-phropathy have been found to be cost-ef-fective in the care of people with type 1diabetes.
Figure 3.
Effect of lipid-lowering medication on the number ofhospital inpatient days according to the 4S Study.IFG = Fasting blood glucose exceeds the normallimit but does not meet the diagnostic criteria fordiabetes.
5. Intensive glycemic control was also foundto be cost-effective in the DCCT Study(USD 20,000/QALY).
The care of type 1 diabetes will become costlyif cuts are made in the key area, the distribu-tion of equipment for self-monitoring ofblood glucose: when self-monitoring by peo-ple with diabetes themselves diminishes, theburden of monitoring glucose balance falls onhealth-care units, and when, due to the short-age of health-care resources, the monitoringthen falls to an insufficient level, complica-tions consequently are apt to develop and theneed for hospital care tends to increase.
Nevertheless, the cost-effectiveness ofthe care of type 1 diabetes can be markedlyimproved if savings in expenses can beachieved in the implementation and monitor-ing of care, for example, in comparison withthe DCCT Study.
Prevention – the Key to Savingsin Diabetes Costs
The message emerging from both Finnish andinternational research is unambiguous: com-plications can be prevented, and investing intheir prevention brings remarkable savings tothe current, very high hospital care costs.Moreover, the prevention of complications isalways cost-effective.
The Helsinki Study showed that the in-crease in mean excess costs (USD per personper year) caused by diabetes was 24 fold intype 2 diabetes and 12 fold in type 1 diabetesafter the patient had developed one or morecomplications (Figure 4). Patients without di-abetic complications (69% of the study popu-lation) accounted for less than 10 per cent ofthe total excess costs caused by diabetes.
SimvastatinPlacebo
1 200
1 000
800
600
400
200
0
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DEHKO 2000-2010
With their sheer number and multiple riskfactors, people with type 2 diabetes are the keygroup with regard to costs. It is worth bring-
Hos
pita
l day
s/10
0 pa
tient
yea
rs
Excess costs ofType 2 diabetes
Without complicationsWith complications
10000
8000
6000
4000
2000
0Excess costs ofType 1diabetes
9625
7418
637395
24x
12x
Figure 4.
Mean excess costs of health care of people withdiabetes (USD/person/year) with and withoutcomplications by the type of diabetes.
ing their care up to date as set out in the DE-HKO action programme.
Although the economic burden of thecare of people with type 1 diabetes on societyis not as heavy as that of type 2 diabetes dueto the lower prevalence of the disease, it is stillimportant to improve its health care andhealth-care organization. When inadequatelytreated, type 1 diabetes is always a life-threat-ening disease and, on an individual level, acostly one because of its severe consequences.
Only rational allocation of resources to-wards the prevention and all-inclusive care oftype 2 diabetes can bring a solution to theproblem of how to prevent the predicted ex-plosive increase in the disease and the multi-ple rise in the costs of its health care. Thesemeasures should be directed to both the entirepopulation and the groups at risk of type 2diabetes. The savings achieved in health-carecosts with the DEHKO programme can bereadily reallocated to other sectors of healthcare.
6. CARE: A PART OF LIFE FOR A PERSONWITH DIABETES
oth type 1 and type 2 diabetes arediseases that last throughout the lifeof a person who has been diagnosedwith them. Both diseases can be suc-
cessfully treated so that it is possible to live anormal, full life in spite of the disease’s every-day presence.
The starting point in the care of diabe-tes is self-care by the person with diabetesbecause nobody else can control the distur-bances in the continuously functioning ener-gy metabolism. The daily care of diabetes isdemanding and requires knowledge, skill, en-durance and motivation. The health out-
comes are primarily dependent on the practi-cal care decisions made by the person withdiabetes, and the responsibility for adaptingthe care to one’s own everyday life lies withoneself.
The person with diabetes and thehealth-care system have distinct roles. It is thetask of the health-care system to make judg-ments on the most suitable care for the personin question and to provide him/her with edu-cation, medical follow up and support, as wellas self-care equipment and drug prescriptions.The person with diabetes is responsible forhis/her own daily care, taking the prescribed
B
23
DEHKO 2000-2010
injections or other medications, measuring outthe food intake, monitoring the blood glucoseand, according to the results, making altera-tions to his/her care according to the agreedguidelines.
Diabetes indeed differs from most otherdiseases in that the person with diabetes is notan object of care but a decisive player inachieving the health outcomes. Hence, as faras their own disease is concerned, people withdiabetes should also be seen as a resource forthe health-care system.
Motivation from Peer Support
Peer support, ie mutual interaction amongpeople with diabetes, is very important. Sincediabetes is a life-long disease that evolves overthe years, the lives of the person with diabetesand his/her immediate family are thoroughlyintertwined with it. The care of diabetes takesplace within everyday life, and the solutionspeople with diabetes themselves find aretherefore also of great value to other peoplesuffering from the same disease.
It is good to share ideas and discoveries,the management of everyday life, and the mo-ments of success and failure in the care of dia-betes; doing so helps both oneself and others.
The local branches of the Finnish Dia-betes Association support the self-care of peo-ple with diabetes in many ways and work inincreasing cooperation with the health-caresystem. Membership of the Finnish DiabetesAssociation and the Diabetes Magazine pro-vide a regular channel for obtaining informa-tion and a support network for a person withdiabetes, thus complementing the services ofthe health-care system in a way that benefitsall parties.
The Role of Patients in ImprovingDiabetes Care
When striving for better health outcomes inthe care of both type 1 and type 2 diabetes,the problems and solutions presented by peo-
ple with diabetes themselves provide impor-tant background information and basic mate-rial to improve the care. The lack of motiva-tion for care, for instance, which is often pre-sented as the reason for poor health outcomes,was found to be a result rather than a cause inan analysis by people with diabetes them-selves. On the basis of this finding, severalpropositions were made for improving thecare system and the cooperation among peo-ple with diabetes, diabetes associations andthe health-care system.
In the early 1990s, the Finnish DiabetesAssociation translated and published a bookletentitled Rights and Roles that was a part ofthe St Vincent Programme support material.A critical analysis of the booklet’s definitionof the role of a person with diabetes showsthat the views presented at the time are still,on the whole, in line with the current way ofthinking.
However, in order to reinforce their self-care, people with diabetes wish to complementthe definition of the patient’s role as follows:
■ A person with diabetes is responsibleabove all to himself/herself for his/her ownhealth; after all, diabetes must be taken intoaccount every day and, in the end, the conse-quences of inadequate care are faced by theperson himself/herself.
■ Responsibility in self-care means that aperson with diabetes really does comply withthe knowledge given and acquired, is commit-ted to self-care and strives to achieve the bestglycemic control possible.
■ A person with diabetes should activelyparticipate in education, nurture a good carerelationship and utilize the available services.
■ The proper use, storage and servicing ofthe self-care equipment so that unnecessarycosts are avoided are also the responsibility ofthe person with diabetes.
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DEHKO 2000-2010
■ The parents of a child with diabetes areresponsible for their child’s self-care and mustattend to the cooperation and communicationamong the different parties that are part ofthe child’s environment (day care, school,hobbies).
A Person with Diabetesin the Care System
In the current financial situation of thehealth-care system it is all the more importantthat people with diabetes and the care person-nel work together to detect inappropriate
modes of operation and to find good andhigh-quality care practices.
With regard to cooperation, it is alsoimportant that people with type 1 or type 2diabetes are accepted as equal experts andmembers of the diabetes teams concerningtheir own disease. In development projects oncare practices, the experiences of people withdiabetes are best utilized by including theirrepresentatives in working groups and com-mittees. The cooperation between the health-care system and diabetes associations in sup-porting the self-care of people with diabetesshould be reinforced in all possible ways.
7. LIFESTYLE MODIFICATION IN THEPREVENTION AND CARE OF DIABETES
n diabetes care, lifestyle modification canprevent complications or markedly delaytheir appearance, as well as decreasing theneed for medication. Lifestyle is especially
significant in the prevention of type 2 diabe-tes.
Essential to the health of a person withdiabetes are smoking cessation, physical activ-ity as an integral part of lifestyle and healthyeating habits. To lower the risks of cardiovas-cular diseases, attention must be paid particu-larly to lowering the intake of hard fats andenergy in overweight people.
Smoking is extremely harmful for theheart and blood vessels. Smoking constrictsblood vessels and predisposes to prematurearteriosclerosis and coronary heart disease, aswell as circulatory disorders of the brain andfeet. Moreover, the minor renal lesions foundin people with diabetes progress faster insmokers.
Physical activity has many benefi-cial effects on the metabolism and functions
of the body. In addition to improving glucosemetabolism, it has a favourable effect on lipidmetabolism and blood pressure and improvesmuscle function, general functional capacityand mood. Furthermore, regular exercise alsoincreases insulin sensitivity and corrects theglycemic control of type 2 diabetes. Exercisehelps both in losing weight and keeping it un-der control.
With a proper diet, most metabolicdisturbances can be simultaneously addressed.Increasing the intake of soft fats and decreas-ing the intake of hard fats down to one-thirdof the total fat intake lowers the LDL choles-terol level. Moreover, soft fats appear to have afavourable effect on blood pressure and insulinresistance.
Food that is high in carbohydrates andfibre, including both soluble and non-solublefibres, has various positive effects on health.This kind of nutritional therapy increases in-sulin sensitivity, decreases the amount of LDLcholesterol in blood and adds to the sense of
I
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DEHKO 2000-2010
being full after a meal. A reduced salt intakedecreases blood pressure in some individuals.People with diabetes are more susceptible thanothers to the harmful effects of sodium.
Individual timing of meals can be usedto influence the post-prandial increase inblood glucose level, sense of hunger and con-trol of eating.
Limiting energy intake in people withtype 2 diabetes corrects insulin resistance andhigh blood glucose, disturbances in lipid me-tabolism and high blood pressure. When highblood glucose is reduced, insulin secretion im-proves.
According to a study by Uusitupa, im-proved nutritional education in the early yearsof the disease can reduce the need for medica-tion in people with type 2 diabetes down toone-third of what people receiving conven-tional care use. On a national level, corre-sponding results would mean annual savingsof millions of US dollars. Nutritional educa-tion in the care of hypertension can result insavings of the same order if not larger.
Organizing Lifestyle Counselling
Achieving lifestyle changes through counsel-ling requires a methodical approach and con-tinuity (also between care units and levels ofcare) on the part of the care organization, useof a common language and agreement oncommon goals.
Diabetes care and education is team-work. A physician, diabetes nurse or a nursefamiliar with diabetes care and a nutritionistparticipate in nutritional education. It is im-portant to agree upon the division of tasks ineach care unit. The services of an expert inphysical exercise are used when possible. Oth-er resources and groups available in the areaare methodically utilized in weight reductionand in guiding the patient to smoking cessa-tion and physical activity.
The implementation of the nutritionaleducation of a person with type 2 diabetes,
monitoring of the success of the diet and con-tinual motivation are primarily the task of thenurse who regularly meets the patient. A nu-tritionist familiar with diabetes care is a mem-ber of the diabetes team and acts as a consult-ant to the physician and the nurse. The con-tribution of the nutritionist is essential in theearly stages of the education of all people withtype 1 diabetes, all children with diabetes andtheir families.
Individual guidance given by a nutrition-ist is needed by those people with diabeteswho have special problems in attaining glyc-emic control or controlling their weight, mul-tiple allergies limiting the use of basic food-stuffs, celiac disease, microalbuminuria or dia-betic nephropathy, gastroparesis or other neu-ropathic problems with eating or the digestivesystem or multiple diseases that must be takeninto account in their diet, or who are undergo-ing great changes in their life situation.
Know-how in nutritional education inthe primary health-care system is enhanced byorganizing a smooth consultation system.Moreover, a chain of nutritional educationshould be established (eg nurse with popula-tion-based responsibility -> diabetes nurse ->nutritionist).
Lifestyle Counselling
Familiarity with the lifestyle of a person withdiabetes, particularly the habits of eating andphysical activity, is essential when the need foralterations is discussed. Such information isalways necessary in situations where startinginsulin treatment or a medication that increas-es insulin secretion is being considered.
The goal of lifestyle counselling is toachieve permanent changes in the behaviourof the person with diabetes. Achieving andmaintaining the changes demand persistenceon the part of both the person with diabeteshimself/herself and the care team. The effectsproduced by guidance on a single occasion areminor.
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DEHKO 2000-2010
Permanent alterations in one’s own customsand habits are a great challenge to a personwith diabetes, and only a few issues can there-fore be focused on at the same time (seeChapter 8).
The method of group counselling is wellsuited to the lifestyle modification of peoplewith diabetes. Issues for diabetic patients, suchas basic information on a proper diet or physi-cal activity, can be discussed in a group situa-tion by utilizing the participants’ own experi-ences. Personal counselling sessions can con-centrate on the practical attainment of the ob-jectives. Counselling aimed at weight reduc-tion and control, as well as smoking cessation,can almost always take place in a group set-ting.
Lifestyle counselling is the very first stepin the care of people with type 2 diabetes. Thecounselling is started immediately after thedisease has been diagnosed. Support andcounselling concerning lifestyle is also contin-ued in connection with transition to drugtherapy.
Realistic Aims
The aims are agreed upon in a joint meetingwith the person with diabetes, the physicianand the diabetes nurse (and other profession-als, as necessary), in which the diabetic pa-tient’s own role in the care is clarified andsuch aims are identified as he/she can acceptand commit himself/herself to. The personwith diabetes should have basic knowledge ofthe disease, its seriousness and care, and thetargets for lifestyle changes should be suffi-ciently low and tangible to allow them to beachieved.
The targets and commitments are re-corded in the patient documents (and the dia-betes registry), and their attainment is system-atically monitored. According to need, the tar-gets are revised, corrected or new additionaltargets are agreed upon.
Special Features ofNutritional Education
People with diabetes are recommended tohave a diet similar to that of the rest of thepopulation in terms of nutritional content.However, people with both type 1 or type 2diabetes need specific dietary instructions inmany respects (Nutritional Recommendationsof the Finnish Diabetes Association).
People with Type 2 Diabetes: BodyWeight Determines the Focus ofLifestyle Counselling
The target for people with type 2 diabetes isnormal weight. Nevertheless, a weight loss of5-10 per cent already has a positive effect, andin some cases it is enough to prevent puttingon more weight.
If a person with type 2 diabetes is ofnormal weight, the counselling primarily con-centrates on the attainment of a healthy diet,finding a suitable rhythm for meals and in-creasing physical activity. Diabetes cannot betreated by not eating. A substantial decrease inglucosuria causes weight increase unless theamount of food intake is somewhat reduced.In order to achieve good glycemic control, itwould be useful to estimate the carbohydratecontent of meals in the case of patients receiv-ing sulphonylurea medication or insulin treat-ment.
In modification of the lifestyle of peoplewith diabetes who are mildly or definitelyoverweight (body mass index, BMI, over 25),it is essential to reduce the energy content ofthe diet by decreasing the amount of food andfat intake and the use of alcohol, to find anappropriate rhythm for meals and to increasephysical activity. In the care of obese individu-als (BMI over 30), a very-low-calorie diet(VLCD) can be used to promote rapid weightloss. When VLCD is used, lifestyle counsel-ling is just as important as when the personloses weight on a regular diet.
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DEHKO 2000-2010
Weight-loss medication can be used to im-prove the results of weight reduction and tosupport the weight control phase. In thesecases, alterations in eating habits also havegreat significance.
If a person with diabetes is not willing tolose weight, he/she may nevertheless be will-ing to make other changes in lifestyle and al-ter his/her diet in an otherwise healthier di-rection.
People with Type 1 Diabetes:Focus on Carbohydrates andthe Diet as a Whole
The lacking insulin secretion in people withtype 1 diabetes is corrected by replacementtherapy. The type, dose and timing of insulinis adjusted to the meal rhythm and other ac-tivities of the person with diabetes as best aspossible. It is essential to the success of thedaily dosage of insulin that the person withdiabetes himself/herself learns to understandthe effects of insulin doses, different food-stuffs and the amount of food, as well as phys-ical activity, on the blood glucose content.
For the care to be successful, it is neces-sary to estimate the amount of carbohydratesin each meal. In the care of type 1 diabetes,the whole diet and its fat composition, as wellas physical activity and not smoking, are im-portant.
Increasing Physical Activity
One of the key goals in the prevention of type2 diabetes is the promotion of regular healthand fitness exercise among the entire popula-tion. Exercise is also of great significance in
the care of all people with diabetes. Over one-fourth of all Finnish people do not exercise atall on a weekly basis during their free time,and only one in seven people report exercisingdaily during their leisure time.
It is recommended that every adultspend at least 30 minutes a day on some formof exercise equivalent to brisk walking interms of load. The exercise may be composedof several shorter periods. In order to maintainmuscle strength, it is recommended that exer-cises involving all large muscle groups shouldbe performed at least twice a week, for exam-ple at a gym.
The foundation for healthy habits ofphysical activity is laid in childhood andyouth. The promotion of children’s and youngpeople’s physical activity is therefore one ofthe most important long-term objectives inthe prevention of type 2 diabetes.
According to epidemiological follow-upstudies, the risk of developing type 2 diabetesis lower among people who exercise regularlyon a weekly basis than among people who donot exercise. The protective effect of physicalactivity is dose dependent: the more frequentthe exercise, the greater its protective effect.
According to a study conducted in theUSA, the risk of developing diabetes was re-duced by 6 per cent for each regular weeklyexercise session corresponding to energy con-sumption of 500 kilocalories. Depending onan individual’s weight and speed, this amountis consumed during 60-90 minutes of walking.The amount of physical activity both duringfree time and at work decreases with age. Thepromotion of physical activity in 50 to 70-year-olds should therefore be given specialemphasis in the prevention of type 2 diabetes.
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T
8. EDUCATION
he patient’s self-care, know-how,qualifications for and attitude to-wards care all have an impact onboth health outcomes and the pro-
gression of the disease. Along with the profes-sional care, the motivation for and learning ofself-care by the person with diabetes himself/herself are prerequisites for good glycemiccontrol and a full life. With diabetes this callsfor continual education based on the needs ofthe person with diabetes, as well as encourage-ment and support from health-care profes-sionals.
A multidisciplinary team is involved inthe education of a person with diabetes. Sucha team consists of a nurse, physician, nutri-tionist, podiatrist and, when necessary, a psy-chologist, social worker and physical therapistor physical education instructor.
Problems in the education of peoplewith diabetes stem from inadequate resources,lack of consensus concerning objectives andthe division of tasks, high staff turnover andlack of experience.
The Basics of Education
The empowerment philosophy in diabetescare stems from the understanding that it isthe people with diabetes themselves whomake the decisions concerning their own careon a daily basis. On the other hand, empower-ment acknowledges that individuals have dif-ferent capacities for assuming responsibilityand allows goals to be set accordingly.
Education is the most essential part ofdiabetes care. It is integral to all professionalcare contacts with a person with diabetes. Itimplies professional and goal-oriented han-
dling of issues concerning diabetes and its carein a situation of equality between the learnerand the educator. Education is a continuousand methodical process, which, however, al-ways proceeds according to the current situa-tion. It is based on an evaluation of the educa-tional needs of the person with diabetes, whois the key evaluator of these needs and setterof the goals. Education supports the learningprocess of the person with diabetes, wherebythe knowledge and skills necessary for the careare reinforced, and the taking of responsibilityfor the care is gradually strengthened.
The working method is client centred sothat the person with diabetes is encouraged totalk about those problems he/she considers tobe the most essential. He/she is listened toand not interrupted. Interviews primarily con-sist of open-ended questions. The aim is toachieve change through a mutually agreedcourse of action.
Personal education is complemented bygroup education. In a group session, peer ex-periences can be shared and discussed, solu-tions to problems can be found, and new ap-plications can be conceived. The group affectspeople’s attitudes. “Healing” elements thatsupport the process of adaptation to a chronicdisease are an integral part of group work.
In a motivational discussion, the personwith diabetes himself/herself evaluates thebenefits and drawbacks of lifestyle alterationsand sets his/her own goals, and the health-care professional encourages him/her to pur-sue them. Inner motivation is reinforced bythe perception of being able to make choices,the optimal nature of the goals and the recog-nition and acceptance of the contradictionsinevitably associated with the process.
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DEHKO 2000-2010
In a client-centred education model that sup-ports the control of diabetes, the followingissues are emphasized:
■ The care relationship is equal and based onshared expertise and responsibility.
■ The person with diabetes recognizes theproblems and learning goals.
■ The person with diabetes is the final im-plementer of care and solver of problems,whereas the professional personnel are a re-source.• Education is intended to enable the person
with diabetes to make conscious choices.
■ Behavioural changes are achieved throughinner motivation.
Assessment and Developmentof Education
The current quality philosophy emphasizes aprocess-oriented and client-centred approach,as well as active participation of health-careprofessionals in continual evaluation and de-velopment of their own work. (Appendix 9)
Client-centredness means that the effec-tiveness of the care is assessed
• in relation to changes in the health of theperson with diabetes
• in relation to the views of the person withdiabetes on how the care and educationhave supported the management of his/herhealth problem
• in relation to how satisfied the person withdiabetes is with his/her care.
Education is assessed together with the personwith diabetes during consultations and in con-nection with annual follow-up visits by deter-mining, for instance, the following:
• the attainment of short-term and long-termcare objectives
• the level of practical diabetes knowledgenecessary in care
• care skills: self-monitoring and its utiliza-tion, evaluation and flexibility of eating, in-jection technique, anticipation and manage-ment of low blood sugar, etc
• biochemical indicators: blood glucose inself-monitoring, glycosylated hemoglobinlevels (HbA1c), weight changes, blood lipids,blood pressure, etc
• care practices: choices of foods, injectionsites, use of medication, foot-care habits,footwear, etc
• lifestyle: smoking, physical activity, etc• satisfaction with care and diabetes-related
quality of life• emotions and moods associated with diabe-
tes, as well as difficulties experienced in lifebecause of the disease
Key elements in improving and developingeducation are the assessment of one’s ownwork, development of educational skills, im-provement of interactive and teamwork abili-ties, as well as appropriate and efficient use ofavailable resources. (Appendix 10)
Increasing cooperation, training, sharingof experiences and research related to educa-tion, both nationally and internationally, helpsthe efficient use and correct allocation of lim-ited resources.
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DEHKO 2000-2010
9. TYPE 2 DIABETES
■ In primary health care, the physician responsible for diabetes care and the diabetesnurse coordinate and supervise their own unit’s educational activity, its implementation,assessment and development in cooperation with the diabetes working group of the hospitaldistrict. The care organization should provide sufficient resources for patient education.
■ Continual education is an essential part of the clinical care of diabetes. Education isintended to promote control of diabetes and to enable the person with diabetes to makeconscious choices.
■ Education is the joint responsibility of all those participating in the care of the person withdiabetes, and its goals and sharing of tasks must be agreed upon within the team.
■ The professional training of those who participate in the care of people with diabetes shouldinclude psychological and interactive skills related to education and the management of a long-term disease. The diabetes teams for children must have special training and skill in their own field.
■ As part of the cumulative patient record, an educator must have a clear, written education planthat is drafted together with the person with diabetes.
■ The needs of special groups (children, young people, women planning on a pregnancy, pregnantwomen, elderly people and people with diabetic complications) must be taken into account.
■ Group programmes are provided for different client groups to support personal education.
■ Methods that complement traditional appointments are introduced, including home visits, themeevents and utilization of information technology.
wo metabolic disturbances arecharacteristic of type 2 diabetes:insulin resistance and low insulinsecretion relative to blood glucose.
People with type 2 diabetes are usually over-weight and often suffer from hypertension,dyslipidemia and abnormalities of hemostasisand coagulation.
Metabolic syndrome precedes type 2 di-abetes. It is caused by lifestyle (physical inac-tivity, overweight) and genetic factors. Thesyndrome has all the features of type 2 diabe-tes except hyperglycemia (Figure 5). Each ele-ment of metabolic syndrome significantly in-creases the risk of cardiovascular disease (cor-
onary heart disease, stroke, peripheral vasculardisease). However, the diagnosis of type 2 dia-betes is still based on the detection of elevatedblood glucose.
Characteristics suggestive of metabolicsyndrome are more common in the Finnishpopulation than among other European popu-lations.
Approximately 15 per cent of peoplewith type 2 diabetes have one of the rarer sub-types of the disease. It is essential to recognizethese subtypes: late-onset type 1 diabetes, ma-turity-onset diabetes of the young (MODY)and mitochondrial diabetes.
T
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DEHKO 2000-2010
Why Is Type 2 Diabetes theCentre of Focus in the DEHKOProgramme?
It has only been understood since the 1980sthat type 2 diabetes is associated with signifi-cant excess mortality from cardiovascular dis-ease. Even with successful treatment of hyper-glycemia it is not possible to correct distur-bances of lipid metabolism, significantly lowerLDL cholesterol levels, reduce blood pressure
Figure 5.
How does type 2 diabetes develop?Genetic factors (type 2 diabetes in the family)Lifestyle (excess energy intake and physicalinactivity)
Metabolic syndrome
• overweight• abnormal lipid profile
(high triglycerides, low HDL cholesterol)• hypertension• abnormal hemostasis and coagulation• IGT (Table 1, page 8)
time passes
Type 2 diabetes
• hyperglycemia• overweight• abnormal lipid profile• hypertension• abnormal hemostasis and coagulation
or correct abnormal hemostasis and coagula-tion.
Treatment of all risk factors for diabetesin addition to blood glucose control signifi-cantly reduces the burden of cardiovasculardisease in type 2 diabetes. Many studies havealso demonstrated the efficacy and cost-effec-tiveness of multifactorial intervention (Tables3 and 4, page 32).The major risk factors for cardiovascular dis-ease are unsatisfactorily or poorly controlled inmore than half of Finnish patients with type 2diabetes (Table 3).
Wanted: a New Attitude and aFocus on Essentials
The greatest obstacle to good care is the pre-vailing perception of type 2 diabetes as a “milddisease” that can be treated by losing weight, aproper diet and oral medication, or, in theworst case, insulin treatment. Cardiovasculardisease that occurs as the major complicationis often treated only by endpoint procedures,such as angioplasty, bypass surgery or otherarterial procedures. The prevention of theseproblems by risk factor management has beenneglected. The knowledge and resources foractive care are still often inadequate, and con-sultation networks between primary healthcare and the diabetes units of specialized med-ical care do not always function as well as de-sired.
To attain better results, the providers ofdiabetes care should adopt new attitudes, aswell as absorbing and putting into practiceknowledge acquired from the most recent re-search.
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DEHKO 2000-2010
Table 3.
Risk factors in patients with type 2 diabetes in Finland
Risk factor Unsatisfactory or poor control Note Per cent
of patients Definition
Hyperglycemia 50% HbA1c ≥ 8.5% Valle et al*Diabetes Care 22: 575(579,1999
Particularly Dyslipidemia 45% S-Trig > 1.7 mmol/ltype 2 63% S-LDL > 3.4 mmol/l Bothnia Study 1999diabetes
Hypertension 80% > 140/90 mmHg National PublicHealth Institute (Tuomilehto)
Particularly Abnormaltype 2 hemostasis > 70%diabetes
*statistics based on a random sample (59 health-care centres, 17 hospitals) of 3,800 patients
Table 4.
Effect of drug treatment of risk factors on cardiovascular events
Risk factor Study Reduction* Change in risk factor Cost-effectiveness proven
Chronic UKPDS –16% HbAIc 7.9 ➝ 7.0% Yes hyperglycemia de Sonnaville: VU University Press,
Amsterdam 1998
High LDL 4 S –55 % LDL chol 4.8 ➝ 3.1 mM Yescholesterol CARE –25% LDL chol 3.6 ➝ 2.6 mM Johannesson: N Engl J Med 336:
LIPID –19% LDL chol 3.8 ➝ 2.9 mM 332–336, 1997
Hypertension UKPDSCAPPPSystEur
–44%–66%–69%
BP –10/–5 mmHgBP –12/–10 mmHgBP –13/–3 mmHg
YesUKPDS Study Group: BMJ 317:720–726, 1998
Abnormalhemostasis
PhysiciansETDRSAntiplateletBIP
–60%–17%–17%–20%
Use of aspirinUse of aspirinUse of aspirinUse of aspirin
Cost of treatment: USD 12/year,does not require follow up un-like treatment of other risk fac-tors ➝ perhaps the most cost-effective way to decrease theincidence of cardiovascular dis-eases in people with diabetes
*myocardial infarction, stroke, coronary heart disease, need for bypass surgery, need for angioplasty, lower-limbamputations
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DEHKO 2000-2010
The key steps to improve the care of peoplewith type 2 diabetes are:
1. developing the care organization
2. increasing the knowledge of physiciansand other health-care professionals aboutthe cardiovascular burden associated withtype 2 diabetes
3. educating patients
4. developing criteria to evaluate the qualityof care
All the above aim at treating the risk factorsfor cardiovascular disease, the major cause ofdeath of patients with type 2 diabetes.
Good Results with the SharedCare Organization Model
The organization of care and systematic eval-uation of the quality of care play a fundamen-tal role in attempts to improve care. A goodexample of this is the intensified care pro-gramme for people with type 2 diabetes thatis currently in progress in the Netherlands.This programme, based on the “AmsterdamShared Care Organization Model”, is entirelyfocused on improving glycemic control, how-ever. In the Netherlands, as in Finland, theprimary health-care system is responsible forthe care of most patients with type 2 diabetes.In the shared care model, the physician re-sponsible for primary health care consults anoutpatient clinic specializing in diabetes carewhenever treatment targets have not beenachieved.
A computerized diabetes registry in theAmsterdam model is the primary tool to
monitor how the treatment targets of cardio-vascular risk factors are achieved in patientswith type 2 diabetes. A regional diabetes coor-dinator is responsible for the registry itself andthe monitoring of the quality of care. Gly-cemic control improved from very poor togood control in 50 per cent of patients alreadyduring the first two years of the programme.In Finland, the FINMIS and FINFAT studieshave shown that in primary health care theglycemic control of patients with type 2 diabe-tes can be significantly improved with a newsimple insulin treatment regimen.
The training of health-care personneland improvement of the communication be-tween primary health care and specializedmedical care are essential in developing theorganization of care of patients with type 2diabetes. It is particularly important to ar-range short-term, flexible consultation servicesto support general practitioners.
It should be possible to consult a special-ized diabetes care unit in situations wherecomplications have already appeared and alsoin situations where the treatment for risk fac-tors has not been successful. Examples of suchsituations include:
• lack of resources to start insulin therapy inthe primary health-care system
• poor glycemic control (HbA1c over 9%)• failure to achieve treatment targets for
blood pressure and blood lipids
Lifestyle Counselling InfluencesMany Risk Factors
Lifestyle counselling is the basis of the care ofpeople with type 2 diabetes (see Chapter 7).
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DEHKO 2000-2010
Hyperglycemia
Fasting blood glucose (fB-gluc) < 6.7 mmol/l(during bedtime insulin treatment 4–6 mmol/l)HbA1c < 7.0%, in insulin treatment < 7.5%
According to a nationwide survey, people withtype 2 diabetes in Finland have very poor gly-cemic control. The national mean proportionof glycosylated hemoglobin (HbA1c), whichreflects the average blood glucose level, was8.6 per cent (Table 3, page 32).
Criteria for Glycemic Control
The target levels for glycemic control in type2 diabetes are as follows:
• optimal glycemic control: HbA1c less than7.0%, in patients receiving insulin treatmentless than 7.5%
• unsatisfactory glycemic control: HbA1c
7.5–8.9%• poor glycemic control: HbA1c over 9%
The normal range is 4.0–6.0%.
The treatment of hyperglycemia has an im-pact primarily on microvascular disease, aswell as on the daily well-being of the patientwith diabetes. The cornerstones of successfulcare are lifestyle counselling, use of optimal
Treatment targets
Table 5.
Treatment of hyperglycemia
Fasting blood glucose fB-gluc > 15 mmol/l(fP-gluc > 17.3 mmol/l)
Lifestyle modification and antihyperglycemic drugtherapy (oral agents or insulin)
Fasting blood glucose fB-gluc 6.7–15 mmol/l(fP-gluc 7.8–17.3 mmol/l)
1. Lifestyle modification2. If fB-gluc remains > 6.7 mmol/l for 3–6 months,
start drug therapy:• metformin if BMI > 25 kg/m2
• sulphonylurea if BMI < 25 kg/m2
• Glitazones are an option for a patient who doesnot tolerate metformin or gets side effects frommetformin or sulphonylurea.
3. If fB-gluc still remains > 6.7 mmol/l, add a secondoral drug.
4. If combination therapy with two oral drugs isunable to lower fB-gluc to 6.7 mmol/l or less:• stop sulphonylurea• continue metformin• start bedtime NPH or glargine• teach self-adjustment of insulin dose
Note that good glycemic control (HbA1c < 7.5%) can not be achieved with bedtime insulin plus oral hypoglycemiccombination therapy unless fasting blood glucose is reduced to 5.5 mmol/l or less.
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DEHKO 2000-2010
doses of oral medication, rapid commence-ment of combination treatment with bedtimeinsulin and metformin (if tolerated) or anoth-er oral agent, as well as self-adjustment of theinsulin dose based on self-monitoring ofblood glucose.
The principles of management of elevat-ed blood glucose are presented in detail inLääkärin käsikirja (“Physicians’ Handbook”,Duodecim Medical Publications Ltd., Helsin-ki). The DEHKO Type 2 Diabetes WorkingGroup has drawn up the revised principles incooperation with the editorial board. Thesame information is available in English on aCD entitled Evidence-Based MedicineGuidelines (also accessible at ). The CD is up-dated three times a year, and the principlespresented in the current edition constitute theprincipal therapeutic recommendations fortype 2 diabetes in primary health care. Therecommendations will be reviewed annually.Table 5 (page 34) presents guidelines for thetreatment of hyperglycemia.
Hypertension
Target
The target level of blood pressure is130/85 mmHg.
40-60 per cent of people with type 2 diabetesalready have elevated blood pressure at thetime of diagnosis. The UKPDS Study showedthat effective treatment of hypertension sig-nificantly reduces and prevents the macrovas-cular and microvascular complications of dia-betes, including the progression of retinopa-thy. Antihypertensive treatments are present-ed in Table 6.
Dyslipidemia
The risk of cardiovascular disease in patientswith type 2 diabetes is so high that drug ther-
apy for dyslipidemia is indicated to achievetarget levels (see page 36) even when the pa-tient does not have signs or symptoms of car-diovascular disease. It is possible to reducemortality, cardiac events and the need for by-pass surgery, as well as angioplasty and otherprocedures among patients with type 2 diabe-tes by lowering their LDL cholesterol levels(Table 4, page 32). To attain target levels, 70per cent of patients with type 2 diabetes re-
Table 6.
Treatment of hypertension
• Non-pharmacological treatment (weight loss,salt restriction, exercise) for all patients
• Cardiovascular events have been shown to bereduced by the following drugs:- low-dose diuretics- selective beta-blockers- ACE inhibitors (or angiotensin II receptor
antagonists if ACE inhibitors are not tolerated)- calcium channel blockers
• Effective treatment of hypertension oftenrequires the use of several drug therapies.
• The patient´s other illnesses affect the choiceof antihypertensive drugs.
Coronary heart disease
• selective beta-blockers
Intermittent claudication, chronic bronchitis orasthma
• diuretics• ACE inhibitors (or angiotensin II receptor
antagonists)
Impotence
• ACE inhibitors (or angiotensin II receptorantagonists)
Metabolic syndrome or significant dyslipidemia
• ACE inhibitors (or angiotensin II receptorantagonists)
Diabetic nephropathy
• ACE inhibitors (or angiotensin II receptorantagonists)
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DEHKO 2000-2010
quire drug therapy for an abnormal lipid pro-file. The 12345 rule serves as a convenient tar-get for lipid-lowering therapy:
• HDL cholesterol >1 mmol/l• triglycerides <2 mmol/l• LDL cholesterol <3 mmol/l• total cholesterol/HDL
cholesterol <4• total cholesterol <5 mmol/l
The guidelines for treatment are presented inthe following table.
Abnormal Hemostasisand Coagulation
Target
Aspirin therapy (100 mg) is recommended in allpatients with type 2 diabetes unless there arecontraindications. Aspirin is contraindicated inpatients who are allergic to it or have hemophil-ia or other bleeding disorders, evidence of gas-trointestinal or other bleeding, including acutebleeding associated with proliferative retinopa-thy. Treated proliferative retinopathy is not acontraindication to aspirin use.
The platelets of a person with type 2 diabetesstick to blood vessel walls more easily than inother people. Use of aspirin reduces cardiovas-cular events on average by 20 per cent in pa-tients with type 2 diabetes.
The benefit of aspirin is indisputable inall patients with type 2 diabetes because therisk of bleeding caused by low-dose aspirin (1/10,000 patient-years) is infinitely small com-pared with the beneficial effects of the therapyon cardiovascular diseases (reduction of ap-proximately 500 myocardial infarctions andstrokes/10,000 patient-years). In Finland,most patients with type 2 diabetes are not cur-rently using aspirin unless they have coronaryheart disease. Aspirin therapy costs approxi-mately USD 12 per year and does not requiremonitoring or screening of patients.
Physicians, other health-care personneland patients with diabetes should be informedthat aspirin therapy is the most cost-effectivemeans of lowering the high prevalence of car-diovascular diseases among patients with dia-betes.
Table 7.
Treatment of dyslipidemia
• Lifestyle changes are sufficient if LDLcholesterol level can be reduced to less than3 mmol/l:- reduce weight, avoid fat, stop smoking,
increase physical activity.
• Intensified treatment of hyperglycemia:- Treatment of hyperglycemia decreases serum
triglyceride concentrations but does notusually decrease the LDL cholesterolconcentration.
• Drug therapy should be started if- LDL cholesterol remains higher than 3
mmol/l.- LDL cholesterol is higher than 4 mmol/l and
the patient belongs to the high-risk group.- triglyceride exceeds 10 mmol/l: use a fibrate
as drug therapy and institute a very-low-fatdiet.
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DEHKO 2000-2010
Benefits from MultifactorialIntervention
The main goal of the care of patients withtype 2 diabetes is to prevent the developmentand progression of cardiovascular disease bythe above-mentioned four-point care pro-gramme targeted at hyperglycemia, hyperten-sion, dyslipidemia and abnormalities in coagu-lation and hemostasis. Another importanttreatment target is smoking cessation. Drugtreatment should not be initiated before theresults of proper lifestyle counselling havebeen evaluated. On the other hand, type 2 di-abetes can be considered a serious cardiovas-cular disease where drug therapy should notbe unnecessarily postponed for too long.
A recent care study conducted in Den-mark on patients with type 2 diabetes demon-strates that the best results are achieved withmultifactorial intervention. In the study, someof the patients continued on conventionalcare, and some had each cardiovascular riskfactor treated. The care team consisted of aphysician, a nurse and a nutritionist.
During a period of four years, the studyshowed that in the group of patients receivingintensified care
• the incidence of diabetic nephropathy wasreduced by 73%.
• disturbances of nerve function were reducedby 68%.
• retinal changes decreased by 55%.• the cardiovascular event rate was signifi-
cantly reduced.
To achieve the above results, the following al-terations in care were required:
• a 15-fold increase in the use of lipid-lower-ing agents
• a 1.5-fold increase in the use of antihyper-tensive agents
• a twofold increase in the use of aspirin• a 14-fold increase in insulin therapy
Similar measures should be undertaken inFinland to reduce the burden of microvascularand especially macrovascular complicationsand the costs associated with the treatment ofthese complications.
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DEHKO 2000-2010
A
10. PREVENTION OF TYPE 2 DIABETES
pproximately 25 per cent of allFinnish people are diagnosed with
type 2 diabetes before their 75thbirthday. In addition, 10-20 per
cent have impaired glucose tolerance (IGT).Currently, there are approximately
50,000 people with undiagnosed diabetes inFinland. People who have high blood glucoselevels but do not yet show symptoms of diabe-tes are at greatly increased risk of developingcardiovascular disease.
Type 2 diabetes is associated with astrong genetic predisposition. It has not yetbeen possible to definitely identify the genesto which this susceptibility is linked. For thepresent, a hereditary tendency to develop dia-betes can be established from the incidence oftype 2 diabetes in the family. Although genesthat expose an individual to a risk of diabetesare probably an essential factor in the develop-ment of the disease, activation of a geneticpredisposition requires the effects of certainenvironmental factors, particularly lifestyle.The most significant factors are clearly over-weight, abdominal obesity and physical inac-tivity.
As early as 1994 an expert group of theWorld Health Organization (WHO) drew uprecommendations for the prevention ofdiabetes and its complications. Theserecommendations strongly emphasized thesignificance of launching preventionprogrammes for type 2 diabetes.
In Finland, there is a strong tradition ofpreventing chronic diseases. Mortality fromcardiovascular diseases, for example, has beenreduced by 60-70 per cent from the rate thatexisted 30 years ago.
The Basis of Prevention
The prevention of type 2 diabetes is based oncontrolling risk factors that can be influenced.In practice, prevention can be realized bytargeting the measures at
1) people who are assessed as being atincreased risk of developing type 2 diabetes
2) the entire population.
These two forms of prevention are notmutually exclusive but reinforce each other. Inplanning national measures for the preventionof type 2 diabetes, both approaches should beused simultaneously.
The High-Risk Strategy
Initially an attempt is made to find those peo-ple from the overall population who are athigher than average risk of developing type 2diabetes (Table 8).
The blood glucose levels of people athigh risk is measured in order to determinewhether they already have asymptomatic dia-betes. Random screening is not recommendedas the primary means of detecting high-riskindividuals in the general population.
If blood glucose testing shows levels ex-ceeding the criteria for diabetes, the individualin question is referred for diabetes care servic-es. In the case of people whose blood glucoselevels do not reach the criteria for diabetes,attempts are made to bring alterable risk fac-tors under as effective control as possible. Theobjective is for the blood glucose level not torise over the years and for other risk factorsfor cardiovascular diseases to be identified andtreated.
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DEHKO 2000-2010
Determination ofDiagnostic Criteria
In putting the high-risk strategy into effect, itis particularly important that the limit valuesused for both the diagnostic criteria of diabe-tes and the different levels of risk factors areclearly defined and based on research evi-dence.
A WHO expert group issued its recom-mendations on the diagnostic criteria for dia-betes in September 1999 (Table 1, page 8).
Implementing Prevention
In the high-risk strategy, the resources of thehealth-care system (and other relevant par-ties, such as private organizations) are direct-ed towards the risk groups with measures toenable the prevention of type 2 diabetes to beimplemented. The reduction of risk factors(hypertension, abnormal lipid profile, over-weight, physical inactivity) in all populationgroups, further follow up of gestational dia-betes and effective health information areemphasized in particular. The specific objec-tives and measures are presented in Tables 9and 10 on page 40.
Population Strategy
In Finland, it is highly likely that at least athird, if not half, of the population have genesthat predispose them to type 2 diabetes. Thismeans that in addition to the strategy targetedat people who are at high risk, measures aimedat the entire population are necessary.
The goals of the population strategy are to
1) influence health habits in such a way thatthe risk factors of diabetes among peoplewho are currently young or middle-ageddo not change adversely over the years, orthat the change is as small as possible
2) change the distribution of known risk fac-tors in the older age groups in such a waythat they are either reduced or at least donot increase.
The population strategy is based on promot-ing healthy lifestyles that are significant to theprevention of type 2 diabetes as well as otherchronic diseases. This requires attitudinal sup-port from society through social norms andviews within the community to encouragethose measures that are implemented in thestrategy targeted at the entire population.
Table 8.
Detecting individuals with a risk of type 2 diabetes
High risk individuals Detection
1. Relatives of people with type 2 diabetes Charting siblings and children
3. People with gestational diabetes Utilization of the blood glucose control records alsoafter giving birth
4. Individuals with elevated blood pressure Determination of blood glucose and lipid levels atan early stage
5. Individuals with slightly elevated blood glucose Follow up and lifestyle counselling
6. Individuals with overweight or abdominal obesity Determination of blood glucose and lipid levels atan early stage
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DEHKO 2000-2010
Table 9.
Objectives of prevention
Indication Objective
1. Age• children• young people
• elderly people
• prevention and treatment of overweightin children
• risk factors kept at a low level, eg target weightis the same as the person´s weight at 20–25years of age
• reducing the increase of risk factors
2. Blood glucose values• hyperglycemia and impaired glucose tolerance• normal blood glucose values
• effective reduction of risk factors, assessment ofthe overall risk of cardiovascular diseases
• prevention of increase in risk factors, assessmentof the overall risk of cardiovascular diseases
3. Cardiovascular risk factors • follow up of blood glucose, reduction ofexisting cardiovascular risk factors, smokingcessation
4. Relatives of people with diabetes • dissemination of information, evaluation ofdiabetes risk with a score questionnaire
5. People with gestational diabetes • weight control, monitoring of blood glucose• one year after giving birth: charting of family
medical history, oral glucose tolerance test,blood pressure and blood lipid profile measuresat the child welfare clinic or maternal health clinic
Table 10.
Action recommended according to follow up data
Indication Action
1. All values normal despite family medical history • oral glucose tolerance test, weight, blood lipidprofile and blood pressure after five years or inconnection with routine health check-ups
2. Levels normal, but BMI over 25 • individual follow up and lifestyle counselling• tests at 2–5 year intervals
3. Oral glucose tolerance test result normal, but • referral to an appropriate care unittype 2 diabetes present in close relatives,blood pressure and/or blood lipid values elevated
4. Diabetes present in close relatives, impaired • referral for diabetes carefasting glucose (IFG), impaired glucose tolerancein oral glucose tolerance test or blood valuesmeet diabetes criteria
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DEHKO 2000-2010
F
Measures directed against smoking in the pre-vention of cancer and successful education ondietary adjustments in the prevention of cardi-ovascular diseases are worth mentioning asgood examples of this kind of populationstrategy.
The same basic principles, objectives andrecommendations that are listed in the ActionPlan for Promoting Finnish Heart Health, setup by the Ministry of Social Affairs andHealth and the Finnish Heart Association, arelargely also applicable at the level of the gen-eral population for the prevention of type 2diabetes. The action programme is the out-come of cooperative work among the variousparties involved. Further broad cooperation isplanned in the implementation phase. TheFinnish Diabetes Association works in closecooperation with the Ministry of Social Af-fairs and Health and the Finnish Heart Asso-ciation in its own action programme.
Implementing Prevention
A strategy targeted at the whole populationcan be implemented through several differentchannels. It is essential that the majority ofthe population recognizes the extent and sig-nificance of diabetes as a public-health prob-lem and that general social and cultural normsare established in line with the objectives ofprevention. However, simply distributing in-formation on health hazards and how to avoidthem is not sufficient as a way of preventingchronic diseases.
The strategy requires special attention tobe paid to the prevention of overweight and amarked increase in physical activity, as well asthe promotion of healthy eating habits (seeChapter 7). Type 2 diabetes is a disease ofslow onset, the prevalence of which increaseswith age. Its prevention therefore cannot beaccomplished rapidly or with a single measure,and the activity must instead be methodicaland sustained over a long period of time.
11. TYPE 1 DIABETES
inland has the world’s highest incidenceof type 1 diabetes (Figure 6, page 42).A total of 30,000 Finnish people havethis type of diabetes, and 3,000 of them
are under 16 years of age. A third of peoplewith type 1 diabetes have developed the dis-ease after reaching the age of 25, and of allpeople who develop diabetes after the age of40, 10-20 per cent have type 1 diabetes. Ap-proximately 450 children each year developdiabetes in Finland. This means that more
than one child is diagnosed with diabetes eve-ry day.
Over the past 50 years, the incidence oftype 1 diabetes in Finland has risen annuallyby over two per cent. In addition, the diseasedevelops at an ever younger age: the numberof children who develop diabetes before theage of five years is increasing at the fastestrate. Although prevention of the disease isalso the most important goal with this type ofdiabetes, for the time being there are noknown means of accomplishing this.
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Figure 6.
Incidence of type 1 diabetes indifferent countries in the 1990s
The most significant problems associatedwith type 1 diabetes in Finland are• poor health outcomes and subsequent
complications• insufficient education• varied practices for monitoring care• lack of resources, particularly with regard
to the care of pediatric patients• inflexibility and ignorance regarding the
transition from young to adult patients
Natural History of the Disease
In type 1 diabetes, the pancreatic cells thatsecrete insulin are destroyed and insulin pro-duction in the body ceases. It is vitally im-portant for the person with diabetes that thislacking hormone, which is essential to life, isreplaced with insulin administered by injec-
tion. Care additionally requires insulin treat-ment, diet, physical activity and other factorsto be harmonized with one another and theireffects on the blood glucose level to be moni-tored. Treatments must also be adjusted wherenecessary so that the blood glucose level re-mains as normal as possible at all times, withno harmfully wide variations.
Once type 1 diabetes has been diag-nosed, it is a life-long disease. The patient’sdaily self-care and self-monitoring of bloodglucose are decisive for health outcome. Insu-lin treatment is primarily given in the form ofmultiple injections.
When the care provided is successful,the person with type 1 diabetes manages inhis/her life just as well as anyone else. Howev-er, long-term diabetes often causes seriouscomplications, the development of which canbe accelerated by hyperglycemia.
The most common of these complications are• retinal disease (diabetic retinopathy), which
can result in blindness• kidney disease (diabetic nephropathy),
which may require dialysis treatment andkidney transplantation
• arteriosclerosis and obstructions of the coro-nary and cerebral arteries, which can resultin myocardial infarction, stroke or gangrenein the legs
• disturbances to peripheral nerve function(diabetic neuropathy)
The complications of diabetes can be prevent-ed by proper and prompt treatment. It is im-portant already to aim at the prevention ofcomplications in the care of child patientswith diabetes because they have their wholelife in front of them.
The Main Goals of Care
In most people with type 1 diabetes, poor gly-cemic control (HbA1c) represents a serious riskof complications. The development of care is
0 10 20 30 40 50
Incidence/100,000/year
4537
282423
2119
1615141313
1110
87
66
21
FinlandSardinia, ItalySwedenCanadaKuwaitNorwayEnglandDenmarkAustraliaItalyHollandSpainEstoniaAustriaHungaryArgentinaTunisiaPolandJapanChina
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DEHKO 2000-2010
necessary in order to improve health outcomesand prevent complications. The main goals are
• good glycemic control without hypoglyc-emia for every person with diabetes
• a skilled, professional diabetes team to sup-port a patient with diabetes in all care units
• provision of the necessary basis for the self-care of a person with diabetes through ap-propriate self-care equipment and adequateeducation that is adapted to different agegroups and needs
• promotion of self-care skills with adaptationtraining and diabetes camp activities
• introduction of new methods of care for thebenefit of people with diabetes
The target levels for glycemic control in type1 diabetes are as follows:
• optimal glycemic control:HbA1c less than 7.5%
• unsatisfactory glycemic control:HbA1c 7.5–8.9%
• poor glycemic control: HbA1c over 9%
The normal range is 4.0–6.0%.
Since type 1 diabetes is a life-long disease,there are several different stages, possible cri-ses and other issues raised by the patient’s ownlife cycle. In addition to the general goals ofcare and education, there are other mattersthat must be considered, particularly amongthe different age groups of people with diabe-tes, especially in children and young people(Table 11, page 44).
Mental perseverance, patience and care-fulness are required to carry out self-care.Continuous support from health-care person-nel and ensuring that the requirements ofself-care are met in all respects are thereforeessential.
In practice, continuous support meanswide-ranging education, a care chain thatworks well and regular follow up and assess-
ment of health outcomes by the diabetes team,in which the person with diabetes or the par-ents of the child with diabetes are equal mem-bers.
Self-Monitoring of Blood Glucose
The self-monitoring of blood glucose by theperson with diabetes, or the parents in thecase of a child with diabetes, is fundamental tothe care of type 1 diabetes. It is an essentialrequirement if the main factors of the care -insulin treatment, nutrition and physical activ-ity – are to be integrated and if good glycemiccontrol is consequently to be achieved.
Education provides people with diabetesand the parents of children with diabetes withthe resources to make the necessary care ad-justments based on the self-monitoring ofblood glucose. The person with diabetes orhis/her parents are encouraged to contact theirdiabetes team if any problems occur.
The self-monitoring of blood glucoserequires appropriate monitoring equipment,such as a blood glucose meter and associatedtest strips. Without them, persons with diabe-tes cannot observe their blood glucose levels,which can vary considerably. The blood glu-cose level can only be monitored by frequentmeasurement.
Regular monitoring is needed to keepthe blood glucose level as normal as possibleso that serious complications are avoided.
Self-monitoring requires a distributionsystem of self-care equipment that works well,adherence to the recommendation of theMedical Advisory Board of the Finnish Dia-betes Association in deciding on the amountsof glucose strips, and sufficient education onboth the use of monitoring equipment and theinterpretation and utilization of the results ofglucose measurement. The blood glucose me-ter also requires frequent calibration so thatreliable results are obtained.
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Objectives of the care and education of people with type 1 diabetes
Good glycemic control without hypoglycemic episodes is the main goal in all age groups.
Age group Objectives of care Education
Children • physical, social and mental well-being;normal growth and development
• support of friends and family• avoidance of severe hypoglycemia• keeping the risk of complications low• careful, continuous follow up
• well-organized initial and extendededucation for the whole family
• follow up that supports self-care• intense cooperation between the care team
and the family• particular attention paid to the growth,
development and special features of the child• follow up visits as necessary in a place that
best suits the needs of the family• involvement of grandparents, day-care
personnel, school teachers and kitchen staffin education
• possibility to participate in education in theform of a course before and during puberty
Adolescents • tailoring the care to meet the needs of ayoung person
• care that supports independence, self-care skills and taking responsibility
• ensuring enough room for a youngperson´s normal development process
• commencement of outpatient careaccording to local situation andresources
• the care team is required to be flexible,to take an individual approach with thepatient, to use modern care practices(new technology, computers, mobilephones, etc.)
• flexibility, security and special attentionto the transfer from the children´s out-patient clinic to the adult outpatientclinic
• methodical education according to theyoung person´s own facilities
• initial education is the most essential;extended education is focused on theassessment of eating habits and independentand flexible administration of insulintreatment
• special attention is paid to the realizationand utilization of the self-monitoring ofblood glucose levels
• checking whether the education has beenproperly understood
• group education (eg courses and camps foryoung people with diabetes) is veryimportant
Adults • acceptance of the disease, commitmentto mutually set care objectives and goodmanagement of self-care
• prevention of complications withthorough care and monitoring
• teaching the basic knowledge and skillsgradually
• the goal is the full understanding ofone´s own responsibility in care andmonitoring
• management of the different factors of careand the means for an independent life
• self-care training
Table 11.
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T
The Care Organization
The care arrangements for people with type 1diabetes are discussed in Chapter 4 (Organi-zation and Resources of Diabetes Care). Thecare organization should be easily approacha-ble; the care must be continuous and flexible;and the care personnel must be skilled profes-sionals. Seamless cooperation between prima-ry health care and specialized medical care isessential. Primary health care units responsiblefor the care of people with type 1 diabetesshould consult specialized medical care when
• the patient’s glycemic control worsens sig-nificantly (HbA1c value repeatedly too highand exceeding 8%) and cannot be broughtunder control with the resources of primaryhealth care
• the person with diabetes develops a prob-lematic tendency towards wide variation inblood glucose levels and/or hypoglycemia
• problems concerning the retinas, kidneys,coronary arteries or feet occur or becomeaggravated.
12. COMPLICATIONS OF DIABETES
he serious complications associatedwith diabetes significantly impairthe patient’s quality of life and causepremature deaths.
The treatment of complications is themost expensive form of diabetes care, andtheir prevention should be invested in at everystage of care and on every level of the careorganization. Poor glycemic control is a majorfactor contributing to the development of thecomplications of diabetes, in addition to otherrisk factors. More attention should thereforebe paid to the quality, follow up and assess-ment of care.
Reducing the complications of diabetesis the most specific of the many objectives ofthe European St Vincent Programme initiatedin 1989. According to these objectives, thefollowing complications should be reduced ineach European country:
• diabetic retinopathy by at least a third• diabetic nephropathy by at least a third
• diabetes-associated lower-limb amputationsby half
• cardiovascular morbidity and mortality inpeople with diabetes
In comparison with many other countries,Finland is highly advanced with regard to dia-betes care. Yet studies show that Finnish peo-ple with diabetes have poor glycemic controland a high prevalence of complications. As anation, Finland has committed itself toputting into practice the objectives of the StVincent Programme, but there is still no com-prehensive picture of the real numbers of dia-betes-related complications or of the trendover the past ten years. This is due partly tothe lack of local and regional diabetes regis-tries.
There is already a kidney disease registrythat works well and a fairly comprehensiveregistry of visual impairments in Finland, butthe information concerning amputations andother complications of diabetes is still diffuse.
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Cardiovascular Diseases
Atherosclerosis, characterized by thickeningand hardening of arterial walls, causes ob-struction of the coronary arteries, cerebralarteries and arteries of the lower limbs andcan lead to dilation of the aorta. All of thesecardiovascular diseases are more common inpeople with diabetes than among the rest ofthe population, and up to 75 per cent of dia-betic patients die from them. The most com-mon problem is coronary heart disease whichcan be manifested as sudden death, myocar-dial infarction, chest pain and heart failure.As a source of costs in diabetes, cardiovascu-lar diseases are in a class of their own (seeChapter 5).
In addition to its commonness, anotherimportant characteristic of coronary heart dis-ease in people with diabetes is its seriousness.Myocardial infarction causes death and heartfailure significantly more often in people withdiabetes than in other people. A first infarc-tion (which often occurs unexpectedly in apreviously asymptomatic person) leads todeath within a year in more than 40 per centof diabetic men and in almost as large a pro-portion of diabetic women. There are few dis-eases as severe as this that occur in the mid-dle-aged population.
The commonness and seriousness ofcoronary heart disease indicates that there is agreat need for prevention. Studies have shownthat prevention is effective. It is needed bothbefore the disease emerges and in people whohave survived it. In both cases, there are clearbenefits to be achieved by treating disturbanc-es of lipid metabolism, aspirin therapy, notsmoking and other lifestyle alterations, as wellas the careful control of blood pressure andblood glucose levels.
The boundary between the preventionand treatment of coronary heart disease isflexible because certain procedures that areusually considered as treatment both improveprognosis and alleviate symptoms. The princi-ples of care of pre-existing heart disease are
essentially the same in people with diabetes asin other people. As diabetic patients have apoorer prognosis, it is particularly importantthat no proven treatment method is omittedunless there are solid grounds for doing so.
The benefits of treatments that improvethe patient’s prognosis are at least as great, ifnot greater, in people with diabetes than innon-diabetic people.
Table 12.
Treatments for coronary heart disease in people with diabetes
In long-term care
• aspirin*• beta-blockers (primarily beta1-selective)*• short-acting and long-acting nitrates• calcium channel blockers
In threatening Q-wave infarction
• aspirin*• thrombolytic therapy on customary grounds*• immediate angioplasty as an alternative or
complementary (when necessary) tothrombolytic therapy*
• insulin and glucose infusion*• ACE inhibitor within 24 hours after symptoms
occur if no contraindications*• other treatment (heparin, beta-blockers, nitrates,
etc.) as with other patients
In an acute coronary syndrome (unstableangina and non-Q-wave infarction)
• does not differ from the treatment of a non-diabetic person:aspirin, heparin, nitrates, consideration ofinvasive procedure; role of platelet glycoproteinIIb/IIIa inhibitors is becoming established in thecare of high-risk patients
Invasive procedure on the same grounds aswith other patients
• bypass surgery (in the most severe forms of thedisease*)
• angioplasty (suggestion of greater benefits thanusual when a stent and GP IIb/IIIa inhibitors areused)
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The treatments that are beneficial in terms ofprognosis, symptoms or both are listed in Ta-ble 12. It should be noted that the previousopposition to thrombolytic therapy of myo-cardial infarction and beta-blockers has prov-en to be unfounded. In myocardial infarction,the infusion of insulin and glucose and theearly initiation of ACE inhibitors seem tobenefit people with diabetes even more thanother people. People with diabetes should bereferred for consultation concerning coronaryangioplasty and bypass surgery on the samegrounds as other people.
Nephropathy
Approximately 30 per cent of people withtype 1 diabetes and 25–50 per cent of peoplewith type 2 diabetes develop diabetic kidneydisease (nephropathy), which may lead to dial-ysis treatment and kidney transplantation. Indiabetic patients, nephropathy is also associat-ed with marked cardiovascular mortality. Inpeople with type 1 diabetes, nephropathy in-creases this risk up to 40-fold. In recent years,there has been an alarming increase in theincidence of nephropathy in people with type2 diabetes.
Diabetic nephropathy worsens the pa-tient’s prognosis and shortens life span. Ac-cording to the DCCT Study, however, neph-ropathy is preventable with intensified care.
The methods for detection and treat-ment of nephropathy have received specialattention in recent years. Development hasbeen most tangible in care strategy: the givencare is more active than previously and it isstarted at an earlier stage, which makes it pos-sible to slow the progression of the disease.
The earliest sign of nephropathy is theappearance of microalbuminuria. Its progres-sion can be retarded by keeping blood glucoseand blood pressure under control, reducing theshare of protein in the diet and giving upsmoking. These are also important measuresin prevention of the development and worsen-
ing of renal insufficiency.All people with type 1 diabetes must be
tested for microalbuminuria annually after theonset of puberty, when they have had diabetesfor at least five years. People with type 2 dia-betes under 70 years of age must be testedonce a year after being diagnosed with diabe-tes. Albuminuria should be measured evenmore often if the person with diabetes is hy-pertensive or has an elevated creatinine level.
If the person with diabetes is diagnosedwith nephropathy, it is important to monitormicroalbuminuria or macroalbuminuria, bloodpressure and glycemic control every 2–3months. The progression of nephropathy canbe prevented with good glycemic control par-ticularly in the early stages of the disease.Treating hypertension has an essential role inprevention: lowering blood pressure reducesthe amount of proteinuria and slows the dete-rioration of renal function in both type 1 andtype 2 diabetes.
The composition of the patient’s diet isalso important because it can influence impor-tant factors of diabetic nephropathy: glycemiccontrol, blood pressure levels, serum lipid val-ues, overweight and, more directly, renal func-tion and proteinuria. Limiting the amount ofprotein in the diet can retard the deteriorationof renal function in both type 1 and type 2diabetes.
The keys to the care and prevention ofdiabetic nephropathy are good glycemic con-trol and the early and regular monitoring andtimely treatment of microalbuminuria.
Retinopathy
The most common eye disease associated withdiabetes is retinopathy. Untreated retinopathyis still the most significant cause of blindnessin people with diabetes.
The prevalence of retinopathy increaseswith the duration of diabetes, so that 80 percent of people with type 1 diabetes developretinal changes within 20 years.
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People with type 2 diabetes, particularly thosetreated with oral medication, have a lowerprevalence of retinopathy (approximately 50per cent after 10 years of diabetes). It is im-portant that both the people with diabetesthemselves and their physicians are aware ofthe risk and that the patients have regular reti-nal examinations.
Retinal changes remain asymptomaticfor a long time. If changes are not detectedbefore eyesight has already deteriorated signif-icantly, the outcomes of treatment are oftenpoor. Regular retinal examinations and theearly detection of changes are therefore essen-tial.
Retinopathy can be detected by ophthal-moscopy, provided that the examiner isknowledgeable and experienced and has prop-er equipment. Nevertheless, retinopathy ismore reliably detected by fundus photographythrough a dilated pupil on either black-and-white or colour film. A fundus examinationshould be performed yearly, or less frequentlyat a physician’s discretion.
Timely and appropriately administeredlaser treatment usually prevents total loss ofvision, but the loss of reading vision is notalways avoidable. The sequelae of intraocularhemorrhage, such as scar tissue that pulls atthe retina, and in some cases retinal edema,are treated with vitreous surgery. If the treat-ment is to be successful, the indications forand appropriate timing of laser treatmentshould receive more attention than they do atpresent.
For the better prevention and treatmentof retinopathy, the significance of frequent reti-nal examinations is emphasized in connectionwith the education of people with diabetes.
Fundus photographic screening has beenshown to be effective in detecting diabeticretinopathy, as well as being an economicalmeans of preventing visual disability. All hos-pital districts should consequently undertakesystematic fundus photography of people withdiabetes.
Diabetic Neuropathy
The occurrence of diabetic neuropathy is re-lated to the patient’s age, duration of diabetes,microvascular diseases and poor glycemic con-trol. Of all of the complications of diabetes,neuropathy is the most difficult with regard toboth diagnostics and treatment.
Neuropathy usually arises as an asymp-tomatic disorder of the peripheral or auto-nomic nervous system. As the diseaseprogresses, the patient develops clinical symp-toms and, later on, other complications. Thesymptom profile and course of the diseasevary on an individual level, although sensorysymptoms can occur at all stages of neuropa-thy.
Neuropathy is associated with manysymptoms that undermine the quality of life.First and foremost it predisposes the patientto foot ulcers, which in turn increase the riskof lower-limb amputation. The symptoms orsequelae of peripheral neuropathy includepain, sensory loss, balance disorders, foot ul-cers and other foot injuries. The symptoms ofautonomic neuropathy include vasomotor dis-orders, gastrointestinal motility disorders,genitourinary dysfunction, abnormal perspira-tion and impaired perception of hypoglyc-emia.
What Can Be Done?
The detection and diagnosis of a disease isessential for its appropriate treatment and theprevention of complications. The treatment ofdiabetic polyneuropathy can be started whenthe following conditions are met:
1. The patient has diabetes with a history oflong-term hyperglycemia.
2. The patient’s predominant symptom/find-ing is sensorimotor neuropathy of the low-er limbs.
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3. Other causes of neuropathy have beenexcluded.
4. The diagnosis is supported by the presenceof retinopathy and nephropathy of approx-imately the same degree of clinical severity.
Diabetic peripheral neuropathy cannot be di-agnosed solely on the basis of symptoms. Thefact that the feet are examined at all is moreimportant than the method of clinical exami-nation. The clinical examination must includetests of sensorimotor function. Of the individ-ual tests, the most highly recommended is thenylon monofilament test which has provedeffective in detecting an impaired sense oftouch. Inability to sense the touch of the ny-lon thread predicts the development of footulcer.
Autonomic neuropathy is difficult toinvestigate in the routine clinical setting, andit is essential to exclude any other conditionscausing similar symptoms.
The presence of neuropathy should bedetermined annually, and if neuropathy is de-tected, the patient’s feet must be inspected atevery scheduled examination. A neuropathypatient is always at risk of developing footproblems regardless of the symptoms.
It is possible to diagnose diabetic neu-ropathy in a doctor’s surgery without specialinvestigations. The level of experience at thecare unit is decisive with regard to the needfor referral for further assessment. Specializedexpertise is required to deal with complicatedneuropathy, differential diagnostic problemsand severe pain symptoms. These cases maynecessitate electroneuromyographic (ENMG)tests conducted by a clinical neurophysiolo-gist.
Treatment of hyperglycemia has beenshown to be decisively important both for theprevention of neuropathy and for slowing itsprogression. There is no specific medicationfor neuropathy, but preventive measures, edu-cation, symptomatic drug therapy and physical
therapy provide possible ways of helping thepatient. Only the treatment of hyperglycemiais preventative or corrective; the symptomatictreatment of neuropathy has no effect on theprogression of the disease.
Essential elements of management:
1. regular examination of feet and routine useof the nylon monofilament test
2. regular monitoring of the condition of thefeet of people at high risk
3. effective treatment of hyperglycemia andother symptomatic treatment (pain symp-toms, erectile disorders, etc)
Foot Problems
Peripheral vascular disease and dysfunction ofthe nervous system expose diabetic patients toa 13-fold risk of lower-limb amputation incomparison with the rest of the population.
It was estimated in the study by Lutherthat approximately 500 full or partial lower-leg amputations are performed in Finland an-nually on people in whom they could havebeen avoided. Most of these patients havetype 2 diabetes.
The Availability of Services Varies
In the study by Virpikari, in which the servic-es, costs and development plans of foot care inhealth-care institutions were studied, it wasfound that foot care and foot therapy are notnecessarily considered to be part of healthcare. The need for foot care to be provided aspart of primary health-care services is not al-ways recognized. Indeed, people with diabetesare often left without appropriate educationand counselling concerning foot care becausefew health-care units include foot specialistsin their diabetes teams.
There are only 40 full-time or part-time
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posts for podiatrists in Finland, half of themin the southern hospital districts. Accordingto Virpikari’s study, most health-care units didnot spend any money in 1996 or budget anymoney for 1997 for foot-care services. Someof the institutions spent as little as 29 US dol-lars on these services in 1996, whereas someinstitutions funded them to the tune of morethan USD 15,000.
The Target of the St VincentProgramme Is AttainableIt is quite possible to attain the St VincentProgramme target of reducing the number oflower-limb amputations by half. Preventivefoot care and foot therapy in people with dia-betes occupy a key position. The active imple-mentation of these services requires more effi-cient distribution of information and trainingof health-care personnel, substantially betterorganization of foot-care and foot-therapyservices and the education of people with dia-betes in foot self-care.
The messages aimed at physicians andother health-care personnel should includethe importance of regular foot examinations,the importance of recognizing feet at risk andexpert care at every stage of foot problems.
The essential elements in recognizing afoot at risk are previous ulcers or amputations,impaired arterial circulation, neuropathy, footdeformities and the other serious complica-tions of diabetes.
Regular Examinations andCare of a Foot at RiskWhen a foot at risk has been detected in aperson with diabetes, education on self-caremust be intensified and the foot must be ex-amined in connection with every scheduled
check-up. Drug treatment that slows the pro-gression of atherosclerosis, optimal glycemiccontrol and smoking cessation assist in pre-venting serious damage. The person with dia-betes is referred to a podiatrist (custom-madeinsoles, etc) and, when necessary, special foot-wear is acquired.
In acute foot problems, the significanceof promptly referring the diabetic patient to aspecialist must be increasingly emphasized togeneral practitioners, and the patients them-selves should be urged to seek professionaladvice as early as possible.
The basic training of physicians andnurses should include a section on the preven-tion and care of diabetic patients’ foot prob-lems. The Recommendation on Diabetic FootCare, drawn up by an expert group of theMedical Advisory Board of the Finnish Dia-betes Association, should be at the disposal ofevery general practitioner. Even other health-care personnel, in addition to those involvedin diabetes care, should be informed aboutfoot problems and their care (a foot problemmay arise when a person with diabetes is hos-pitalized in a department other than internalmedicine). The chapter in the Physicians’Handbook that deals with the prevention andcare of diabetic foot problems should be up-dated regularly.
The foot-care organization should bedeveloped by improving the accessibility ofthe services of podiatrists throughout thecountry either by creating more posts in hos-pitals and health-care centres or by increasingthe purchase of foot-care services providedprivately.
It is essential to establish a multiprofes-sional foot-care working group in every cen-tral hospital and to increase the capacity ofvascular surgery.
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Table 13.
Perinatal mortality in type 1 diabetes patients at the Department of Obstetrics and Gynecolo-gy of the Helsinki University Central Hospital between 1951 and 1997 and annual perinatalmortality in Finland during the same period
1951–60 162 16 30 16 46 28.5 3.21
1959–68 231 23 25 23 48 20.8 2.32
1970–71 52 26 3 4 7 13.5 …
1975–80 279 47 3 3 6 2.2 1.25
1988–97 702 70 10 7 17 2.4 0.68
*annual mean (Finnish Statistical Yearbook 1997)
Perinatal mortality
Year Children; total
Children/year
Stillborn Died within 1week of birth
Women with type 1 Finland
13. DIABETES AND PREGNANCY
Type 1 Diabetes
Every year, there are approximately 300 deliv-eries among women with type 1 diabetes inFinland. The number has more than doubledin the past 25 years, as a result of the continu-ous increase in the incidence of diabetes inFinland (see p. 42).
Perinatal mortality has decreased fromover 30 per cent to 2–4 per cent in the past 50years. However, even in centres specializing inthe follow up and care of pregnant womenwith diabetes, perinatal mortality in womenwith diabetes is still 3–6 times higher than inthe population as a whole. In the smaller ma-ternity hospitals, the situation is even worse.
Because perinatal mortality has not de-creased over the past 25 years, the absolutenumber of perinatal deaths has clearly in-creased (Table 13). Approximately a third ofthe deaths are caused by malformations, athird by prematurity and a third by asphyxia.
The frequency of malformations amongthe children of women with type 1 diabetes is
5-8 per cent, which is 2–4 times more thanamong the general population. The problem ismade even more serious by the fact that themalformations in the children of women withdiabetes are clearly more severe than thoseamong other children, which increases perina-tal morbidity and mortality.
Poor glycemic control (high HbA1c) dur-ing early pregnancy explains a significant por-tion of the malformations among the childrenof women with type 1 diabetes.
The risk of malformations can be mark-edly decreased by improving diabetic women’sglycemic control before pregnancy. Recentstudies demonstrate that the incidence of mal-formations is directly related to the HbA1c
value during the first trimester of pregnancy.-In addition, there is no indication of a thresh-old value above which malformations are morelikely to occur.
This means that an attempt must bemade to ensure that all pregnancies amongwomen with diabetes are planned in advance,and that their glycemic control is as good as
diabetes N % %
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Pathological glucose values (mmol/l)
Amount of 0 h 1 h 2 h
Plasma ≥4.8 ≥10.0 ≥8.7
Venous whole blood ≥4.5 ≥9.1 ≥7.9
*97.5 percentile/values(Recommendation of the Pregnancy Working Group ofthe Finnish Diabetes Association)
Table 14.
Diagnostic limit values* forgestational diabetes in the 2-houroral glucose (75 mg) tolerance test
possible before the pregnancy begins. In prac-tice, contraception can be stopped whenHbA1c is below 7.5 per cent.
Regular check-ups and counselling be-fore pregnancy are best undertaken in the ma-ternity outpatient clinics of central hospitals.
New statistics from Northern Ireland,Sweden and Denmark show that the perinatalmortality of children of women with type 1diabetes is lower in large maternity hospitalsspecialized in the care of these patients. Theresults worsen markedly if a woman with dia-betes is not referred from a small hospital to acentral hospital until late in pregnancy.
For contraception, low-estrogen combi-nation oral contraceptives and intrauterinecontraceptive devices (IUDs) are almost invar-iably also suitable for women with diabetes.
Gestational Diabetes
Gestational diabetes is defined as a disorder ofenergy metabolism that is detected for thefirst time during pregnancy. In other respects,there is unanimity about the criteria of gesta-tional diabetes.
Diagnosis
In Finland, a 2-hour oral glucose (75 g) toler-ance test is used in diagnosing gestational dia-betes. The diagnostic criteria of gestationaldiabetes are based on the agreed abnormalvalues in the glucose tolerance test, not on thebiological consequences (i.e. macrosomia ofthe fetus). Table 14 presents the diagnosticplasma glucose values based on a Finnish pop-ulation survey.
The fact that venous whole blood, capil-lary whole blood or plasma are still used sideby side in blood glucose measurement in Fin-land presents a problem. Measuring plasmaglucose is the method to be recommended,and it is essential to agree upon uniform prac-tice in this matter.
Follow up and Care
It is possible, even today, for the need for anoral glucose tolerance test not to be noticeduntil a woman arrives at a hospital to givebirth. This kind of negligence can endangerthe health of both the fetus and newborn, andthe risk groups for gestational diabetes shouldtherefore always be monitored.
Risk factors for gestational diabetes
• morning glucosuria
• overweight mother (BMI > 25)
• mother has previously given birth to an infantover 4500 g of weight
• macrosomic fetus
• mother 40 years of age or older
• gestational diabetes detected during previouspregnancy
If only one abnormal value is detected in theoral glucose tolerance test, the maternal healthcentre will give the mother nutritional in-structions and a referral to the maternity out-patient clinic of the hospital where the birth isplanned to take place. The outpatient clinicwill then monitor the growth of the fetus and
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the mother’s compliance with her nutritionaltherapy.
Two routine visits (at approximatelyweeks 30 and 37 of gestation) at a maternityoutpatient clinic are sufficient for women withdiabetes treated with nutritional therapy be-cause of their low risk of having a macrosomicfetus.
In case there are two or more abnormalvalues in the oral glucose tolerance test, thematernal health centre will refer the mother toa hospital where a 24-hour blood glucose pro-file is performed during nutritional therapy. Itis recommended that blood glucose be meas-ured every 4 h.
Insulin treatment is commenced if twoof the preprandial values exceed 5.5 mmol/l,or if one value exceeds 5.5 mmol/l and onepostprandial value exceeds 7.8 mmol/l. Ap-proximately one-third of pregnant womenwho have two or three pathological values inthe 2-hour oral glucose tolerance test needinsulin treatment in addition to nutritionaltherapy for the rest of the pregnancy.
In cases where the 24-hour blood glu-cose profile indicates that insulin treatment isnecessary (White’s class A/B), the mother willbe admitted to a hospital specialized in care ofthe pregnancies and births of women withtype 1 diabetes, for the initiation of treatment.
The risk of fetal death and macrosomiain these patients (>2 standard deviations [SD]above the mean for a Finnish reference popu-lation) is about the same as in patients withtype 1 diabetes.
Screening
The most important aim of screening for ges-tational diabetes is to find those women whohave a clearly increased risk of having a mac-rosomic fetus due to elevated blood glucoselevels. According to the most recent interna-tional recommendations, it is sufficient toscreen only those groups of women who are atrisk of developing gestational diabetes. This
principle has been followed in Finland forseveral years.
It is important that the 2-hour oral glu-cose tolerance test is conducted in full (with0-hour, 1-hour and 2-hour values). If only onevalue out of the three is abnormal (5–6 percent of pregnant women), nutritional therapyis sufficient. In these women, the risk of fetalmacrosomia is no greater than in healthywomen.
In cases where two or three of the oralglucose tolerance test values are pathological(1 per cent of pregnant women), it is necessaryto start insulin therapy in addition to nutritiontherapy (in 30 per cent of cases). The recordsof the Department of Obstetrics and Gyne-cology of Helsinki University Central Hospi-tal show fetal macrosomia in 16 per cent ofthis group of patients.
The Effect of Gestational Diabeteson Women’s Health Later in Life
Gestational diabetes is primarily a risk factorfor type 2 diabetes. Up to 50 per cent of wom-en who have had gestational diabetes developtype 2 diabetes over the next 10–15 years. Ap-proximately 10 per cent of women who havehad gestational diabetes will go on to developtype 1 diabetes.
In the maternity hospital, mothers whohave had gestational diabetes are providedwith written instructions for future follow upand information on the symptoms of diabetes,as well as the benefits of diet, physical activityand normal weight. Health-care centresshould recognize these women’s risk of devel-oping type 2 diabetes later in their lives.
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A
14. QUALITY IMPROVEMENT ANDDIABETES REGISTRIES
diabetes registry is an essential in-strument for quality control and theassessment of care. As far as isknown, no registry that works per-
fectly has yet been developed, but there arevarious versions of diabetes registries aroundthe world. The DiabCare system developed inconnection with the St Vincent Programme isin use in many countries but has not yet wonbroad acceptance.
According to a report by the NationalResearch and Development Centre for Wel-fare and Health (STAKES) in 1996, therewere about a dozen local or regional diabetesregistries in Finland at that time, but theirdata content and technical structure variedwidely. Approximately 70–80 per cent ofhealth-care centres use electronic patientrecord systems (eg Sinuhe, Pegasos or Fin-star). Patient record systems that are accessiblethrough data networks and include electronicreferral and feedback functions are currentlyunder development in various hospital dis-tricts. The Association of Finnish Local andRegional Authorities has started a projectaimed at creating uniform standards for all thesystems currently under development. Therevised discharge notification practice is wellestablished at national level and operatessmoothly.
The need for diabetes registries is clearlyrecognized in different quarters. Health-careunits are expected to check the quality of theiractivities, which requires a good documenta-tion and feedback system. Methodical collec-tion of information at all levels is necessary inorder to assess the implementation of the StVincent Programme and to improve interna-tional comparability. Finland has a good repu-
tation internationally for its diabetes research,and this reputation should also be nurtured inthe quality control of diabetes care. There ap-pear to be regional differences in the quality ofdiabetes care which have been observed incertain reports. The recognition of inequalityand the needs for revisions can be facilitatedby having a uniform system of documentationand feedback.
The Purpose ofa Diabetes Registry
A diabetes registry makes it possible to moni-tor the provision of care at all levels of the carechain. A diabetes registry should be construct-ed at three levels:
At the operational unit level (health-carecentres, occupational health care, hospitals,units specializing in diabetes care either inhealth-care centres or hospitals), the mostimportant function of the registry is that dia-betic patients can be identified, the quality ofcare can be monitored, and certain specialmeasures, such as screening for retinopathy,can be undertaken in either a comprehensiveor targeted manner. The registry also helps toidentify people who fall outside the care chainand regular monitoring. A diabetes registry ispart of the normal patient record system andanswers the question as to whether the care isoptimal with regard to a particular patient. Inindividual care situations, the registry canfunction as an aid to education, as well as areminder system for undertaking agreed meas-ures and attaining care objectives.
The registry also allows parameters to bemonitored that describe the care of a personwith diabetes on a long-term basis. In a care
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DEHKO 2000-2010
situation, the care unit has access to both cus-tomised samples of desired information andannual feedback. A diabetes care informationsystem could be employed as the primary soft-ware in units specializing in diabetes care (di-abetes consultation centres, diabetes outpa-tient clinics).
At the regional level, the registry moni-tors and compares the quality and health out-comes of the services provided by differentoperational units. The registry can also help toimprove communication between the unitsparticipating in the care. The registry is main-tained by each hospital district and has twotypes of data flows:
1. A flexible flow of data concerning apatient’s care between his/her care units.The patient’s consent is required for thedata transfer.
2. Summary data concerning the performanceof the operational units, in which clientidentification is not required. This informa-tion is utilized in monitoring quality.
At the regional level, responsible persons ap-pointed by the hospital districts are taskedwith ensuring that information is filed in theregistry at regular intervals, as well as report-ing and providing feedback to the operationalunits. Feedback concerning the quality of careis given to the operational units in the form ofbenchmarking in relation to average levels inthe district or in relation to other correspond-ing operational units.
At a national level, the registry providesinformation on how diabetes care is imple-mented in different parts of the country,pointing out regional differences and needsfor improvement. The data on the quality ofcare relate to operational units, not to individ-ual patients.
The person responsible for the nationaldiabetes registry acts as a link to the regionallevel and to the National Research and Devel-
opment Centre for Welfare and Health(STAKES), also checking the receipt of infor-mation, the commensurability of the data andthe functionality of the registry system andtaking care of reporting. Data relating to indi-vidual operational units (at least the indicatorsof the mean level of HbA1c and complications)are gathered from the regional registries oncea year.
The Creation and Maintenance ofa Diabetes Registry
A diabetes registry should be uncomplicatedand straightforward to create on the basis ofthe present patient record systems or an asso-ciated diabetes follow-up system. The startingpoint consists of a ‘diabetes database’ at thehospital district level (it may be part of a re-gional diabetes care data system), the electron-ic patient record and laboratory software pres-ently in use in the districts and the reviseddischarge notification system. The indicatorsthat describe the provision and quality of careare recorded in the registry in a structured andcomparable form.
At the operational unit level, the objec-tive is to have all people with diabetes withinthe range of the registry. A diabetes nurse orphysician responsible for diabetes care is ap-pointed as the person responsible for the reg-istry. He/she acts as a link and is responsiblefor the correctness of the data and the transferof the data from the operational unit registryto the regional registry.
In the care situation of an individualpatient, the data are registered as part of thenormal electronic patient record system. Thenecessary data on the monitoring of care arerecorded in a structured form in the system.(Appendix 11). The patient’s written consentis required for joint use of patient record dataamong the different service levels.
The electronic patient record systems ofhealth-care centres and occupational health-care units should allow data to be transferred
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DEHKO 2000-2010
to a regional registry. New patients are enteredin the registry at the time when diabetes isdiagnosed. Later on, the patient record data-base recognizes the diabetic patient and auto-matically activates the diabetes software. Thedata that describe the provision of the careand the attainment of the care objectives aregathered in the regional registry on a yearlybasis.
In cases where there is no electronic pa-tient record system in use at an operationalunit, a manual registry is used. The annualdata are then gathered by using a loggingform. The responsible person takes care offilling in the form and sends it to the regionalregistry every year.
The data relating to a patient who hasbeen in hospital care are directly transferredfrom the electronic discharge notification tothe diabetes database, and other hospital in-formation concerning the patient (eg casesummary) is transferred to a broader diabetes
data system with the patient’s consent.Among people with diabetes, the infor-
mation to be recorded should cover glycemiccontrol, diabetic foot ulcers, amputations, lasersurgery, visual impairment, blindness, myocar-dial infarctions, angioplasties, bypass surgery,strokes, initiation of dialysis treatment andkidney transplantations.
Legislative Basis
The following legislation concerning personaldata protection and the processing of docu-ments is relevant to setting up and maintain-ing of a diabetes registry: Personal Data Act(523/1999), Act on the Openness of Govern-ment Activities (621/1999), Decree on theOpenness of Government Activities andGood Data Management Practice (1030/1999) and Act on the Status and Rights ofPatients (785/1992).
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T
15. RECOMMENDATIONS FOR ACTION
he recommendations have been col-lected in such a way that at the be-ginning there are Key Actionswhich, when put into effect, enable
the whole programme to be implemented.After this, Recommendations for Action Ac-cording to Content are presented for the im-provement of diabetes prevention and care.
Key Actors refer to those organizations,authorities, working groups and professionalswhose field of work is relevant to the recom-mendation in question. The recommendationsfor action are proposals made to these partiesto start research on how to initiate the pro-gramme in their own organization/unit andwhat results can be achieved in cooperationwith other parties.
The Finnish Diabetes Association togetherwith its cooperative partners monitors theimplementation of all the recommendationsfor action. Other relevant parties whose activi-ties essentially include Follow up of the devel-opment work are also mentioned below.
The Finnish Diabetes Association andother parties connected with the action pro-gramme will implement it in accordance withthe facilities and resources of their own organ-ization. They will therefore also schedule theirown activities according to their own circum-stances. The Finnish Diabetes Associationwill promote the launching of the programmeby publishing information and educationalmaterial about it which the care units can uti-lize in their activities.
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DEHKO 2000-2010
RECOMMENDATION KEY ACTIONS ANDFOLLOW UP
KEY ACTIONS
1. Prevention of type 2 diabetes is listed as one ofFinland’s health policy objectives in the WHO Healthfor All in the 21st Century Programme. A nationaloverall plan is outlined for the prevention programme,and the necessary funding is allocated to it. A broadpublic awareness campaign is organized to initiateprevention.
Actors: Ministry of Social Affairs and Health,Advisory Board for Public Health/Sub-Committee on Cardiovascular Diseases andDiabetes, Finnish Diabetes Association
Follow up: Ministry of Social Affairs andHealth, Advisory Board for Public Health/Sub-Committee on Cardiovascular Diseases andDiabetes, National Public Health Institute
2. The non-pharmacological therapy of type 2 diabetes isimproved, and annual monitoring of cardiovascular riskfactors and treatment of cardiovascular diseases areorganized in all care units of the primary health-caresystem.
Actors: chief physician, physician responsiblefor diabetes care, diabetes nurses
Follow up: diabetes working group of thehospital district, Medical Advisory Board of theFinnish Diabetes Association, Sub-Committeeon Cardiovascular Diseases and Diabetes
3. The criteria for granting preferential reimbursement ofdrugs are altered to favour the lowering of cardiovascularrisk factors. Lipid-lowering agents should be grantedpreferential reimbursement status for all diabetic patientswho need them. People with diabetes should be able tostart using antilipemic and antihypertensive drugs withpreferential reimbursement on less strict indications thanthose required for non-diabetic people.
Actors: Ministry of Social Affairs and Health,The Social Insurance Institution
Follow up: Finnish Diabetes Association andits Medical Advisory Board
4. Uniform quality criteria for diabetes care areintroduced in Finland, which all units that providediabetes care (specialized medical care/primary healthcare) must meet as adapted to local circumstances. Theproposal presented in Appendix 9 provides an exampleof the assessment of the quality of education.
Actors: National Research and DevelopmentCentre for Welfare and Health (STAKES), chiefphysician or medical director or physician re-sponsible for diabetes care of the care unit/physi-cian responsible for diabetes care, diabetes nurse
Follow up: diabetes working group of thehospital district, provincial government, FinnishDiabetes Association
5. In order to monitor, assess and improve quality, a three-level diabetes registry is established in Finland, consist-ing of operational unit registries, regional registries anda national registry. In order to put a national diabetesregistry into effect, a survey of the current situation iscarried out and a pilot project is initiated.
Actors:National level: Finnish Diabetes Association,National Research and Development Centre forWelfare and Health (STAKES), National PublicHealth InstituteRegional level: hospital district, diabetesworking group of the hospital districtOperational unit: medical director, physicianresponsible for diabetes care, diabetes nurse
Follow up: hospital district, diabetes workinggroup of the hospital district, Finnish DiabetesAssociation, National Research and Develop-ment Centre for Welfare and Health (STAKES),National Public Health Institute
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DEHKO 2000-2010
6. In order to make self-care possible, all people with diabe-tes are guaranteed individual and continuous education.The distribution of self-care equipment is appropriatelyorganized following the recommendations of the MedicalAdvisory Board of the Finnish Diabetes Association andthose of the Ministry of Social Affairs and Health (Appendix 12).
Actors: chief physician or medical director ofthe care unit, physician responsible for diabetescare, diabetes nurse
Follow up: diabetes working group of thehospital district
7. Every health-care centre should have an appointedphysician responsible for diabetes care and a diabetesnurse who coordinate diabetes care, training and qualitycontrol in their health-care centre. Each unit of specializedmedical care should have an appointed diabetes teamheaded by a specialized physician in charge of diabetes care(the responsible physician). The services of at least apodiatrist, nutritionist, psychologist and physical therapistor physical education instructor should be at the disposalof the diabetes teams both in the primary health-care andthe specialized medical care system. A person with diabetesis an equal member of the diabetes team in his/her care unit.
Actors: medical director, physicianresponsible for diabetes care, diabetes nurse,executive chief physician, chief physician of theunit of specialized medical care, director of thedepartment or profit centre, person withdiabetes
Follow up: diabetes working group of thehospital district
8. Every hospital district should have an appointed diabetesworking group, whose task is to improve and coordinatediabetes care (Appendix 3). In addition to the different careunits (including occupational health care and the privatesector), people with diabetes should be represented in theworking group.
Actors: hospital district
Follow up: hospital district, provincialgovernment, Finnish Diabetes Association
9. Diabetes awareness and know-how is promoted in allsectors of health care.
a) Special attention is paid to the training of physicians andnurses in occupational health care and the population-based responsibility system.
c) A diabetes education programme is set up for physicians.
d) Nurses’ professional education in diabetes care andeducation is developed in line with the Key Role of theDiabetes Nurse Project.
e) A multiprofessional training programme in education isestablished.
Actors: health-care centre, hospital district,Finnish Diabetes Association, medical specialitysocieties, medical schools, Association ofFinnish Diabetes Nurses, Association of Clinicaland Public Health Nutritionists in Finland,Finnish Association of Podiatry, pharmacies,biomedical industry, Finnish Diabetes EducationStudy Group (DESG)
Follow up: health-care centre, hospitaldistrict, diabetes working group of the hospitaldistrict
10.Cooperation between the specialized medical care systemand the primary health-care system is further developed tobe a two-way channel and more flexible than at presentespecially with regard to consultation options. Acomprehensive and high-quality care chain for the care ofpeople with diabetes is created in all hospital districts(Appendices 13-16).
Actors: hospital district, diabetes workinggroup of the hospital district
Follow up: diabetes working group of thehospital district, Finnish Diabetes Association
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DEHKO 2000-2010
PROPOSITIONS FOR ACTION ACCORDING TO CONTENT
• The monitoring of the quality and results of care isimproved in order to detect diabetic complications at anearly stage and prevent them with the aid of regularannual check-ups. The cooperation among care units ismade more flexible so that appropriate care for a personwith diabetes can be started without delay in a care unitat the right level.
Actors: care unit, hospital district
Follow up: care unit, hospital district, diabetesworking group of the hospital district
• In order to assess the resources for efficient care andeducation, the requirement for diabetes nurses, podia-trists and nutritionists is analysed. The requirement fordiabetes expertise within the health-care personnel isdetermined.
Actors: Finnish Diabetes Association, Ministryof Education, National Board of Education,Ministry of Social Affairs and Health
Follow up: Ministry of Social Affairs andHealth, Sub-Committee on CardiovascularDiseases and Diabetes of the Advisory Board forPublic Health
• A foot-care team is appointed in every central hospital(Appendix 8).
Actors: executive chief physician, diabetesworking group of the hospital district
Follow up: hospital district, diabetes workinggroup of the hospital district, health-care centres
• Regular centralized fundus photography of diabeticpatients is arranged in each hospital district yearly or, ifdeemed appropriate, less frequently.
Actors: hospital district
Follow up: health-care centres, hospitaldistrict, diabetes working group of the hospitaldistrict
• Oral health care for people with diabetes is arranged inhealth-care centres in a similar way as for other specialgroups.
Actors: health-care centre
Follow up: diabetes working group of thehospital district
• A comprehensive system is set up for the quality controland development of the equipment used in monitoringcare.
Actors: manufacturers of care equipment, careunits, diabetes working group of the hospitaldistrict
Follow up: care units, hospital district,diabetes working group of the hospital district
Care: a part of life for a person with diabetes
• The cooperation between the health-care system andthe local branches of the Finnish Diabetes Association isenhanced throughout Finland particularly with regard tothe dissemination of information, training, peer supportactivities and the provision of self-care and monitoring ofits resources.
Actors: persons responsible for diabetes carein health-care centres, local branches of theFinnish Diabetes Association
Follow up: regional secretaries and regionalcommittee of the Finnish Diabetes Association
• The expertise of people with diabetes is utilized in thedevelopment of care practices and new care equipment.
Actors: persons responsible for diabetescare in all care units, manufacturers of careequipment
Follow up: local branch and regionalcommittee of the Finnish Diabetes Association
Care organization and resources
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DEHKO 2000-2010
Education
Actors: DESG (Finland), Association of FinnishDiabetes Nurses, Finnish Diabetes Association
Follow up: DESG (Finland)
• On the basis of programmes and methods already in use,a basic model of education is developed to be locallyadapted.
• A uniform national ‘diabetes pass’, i.e. a model of monitoringcare that is an adaptation to Finnish circumstances of aEuropean model, is introduced.
Actors: Finnish Diabetes Association,diabetes working group of the hospital district
Follow up: Finnish Diabetes Association,care unit, diabetes working group of thehospital district
Prevention of type 2 diabetes
• The units of the primary health-care system outline a planof how to recognize high-risk individuals and implementpreventative measures.
Actors: health-care centres, occupationalhealth care
Follow up: care units, diabetes workinggroup of the hospital district
• The Action Plan for Promoting Finnish Heart Health isapplied in the prevention of type 2 diabetes, particularlywith regard to meals in institutional settings, foodstuffsymbols, training and communication.
Actors: Finnish Diabetes Association, FinnishHeart Association, Advisory Board for PublicHealth, National Nutrition Council
Follow up: Finnish Diabetes Association,Finnish Heart Association, other partiesconcerned, Advisory Board for Public Health/Sub-Committee on Cardiovascular Diseasesand Diabetes
• The availability of special services for children and youngpeople is ensured, and the smooth transfer of thesepatients at the correct stage of their development to thecare of a high-quality unit responsible for adults withdiabetes is guaranteed.
The physical activity of the entire population is promoted byenhancing the cooperation among the health-care system,sports organizations, schools and public health organizations.Systematic prevention of obesity is initiated.
Actors: public health organizations, sportsorganizations, Ministry of Education, Ministryof Social Affairs and Health/Department forPromotion of Welfare and Health, Fit for LifeProgramme
Follow up: Advisory Board for Public Health/Sub-Committee on Cardiovascular Diseases andDiabetes, Fit for Life Programme, Ministry of So-cial Affairs and Health, Ministry of Education
Type 1 diabetes
• The education of people with type 1 diabetes is improvedin all age groups to achieve better control of the diseaseand to avoid the complications of diabetes.
Actors: all care units dealing with type 1diabetes
Follow up: operational unit, regionalregistry
Actors: hospital district, physicianresponsible for diabetes care in the care unit,diabetes nurse, diabetes working group of thehospital district
Follow up: diabetes working group of thehospital district
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DEHKO 2000-2010
16. The Composition of the Working Groups
Care Organization and Resources
Chairperson:Professor Matti Uusitupa
Secretary:Ms Keiju Pääskynkivi, Secretary of DEHKO
Dr Stig Bergkulla, InternistMs Leena Etu-Seppälä,Secretary General of DEHKOMr Jorma Huttunen, Managing DirectorMs Liisa Hyvärinen, Diabetes NurseProfessor Tero KangasDr Jorma Kivekäs, Medical DirectorDr Heikki Oksa, Chief PhysicianDr Seppo Salo, Chief PhysicianDr Jouko Saramies, Medical DirectorMs Marjatta Stenius-Kaukonen,Member of Parliament
Diabetes Cost
Chairperson:Professor Tero Kangas
Ms Leena Etu-Seppälä,Secretary General of DEHKOMr Unto Häkkinen, Research ManagerProfessor Sirkka Keinänen-KiukaanniemiProfessor Antero KesäniemiProfessor Timo StrandbergProfessor Jaakko TuomilehtoProfessor Hannele Yki-Järvinen
The Role of a Person with Diabetes
Chairperson:Ms Tuula Lehto, Organization Manager
Southern Finland:Mr Erkki Rantanen, Paramedic
Ms Kirsti Talsi-Sirkka, JournalistMs Hannele Österberg, Undergraduate Student of Po-litical Science
Western Finland:Mr Matti Kataja, DrTech, Assistant ProfessorMr Hannu Kesonen, TechnicianMr Erkki Poukkula-Kaartinen, AccountantMs Irmeli Salonen, Social Counsellor
Eastern Finland:Mr Teuvo Juvenius, Radio MechanicMr Erkka Ollila, Municipal DirectorMr Ismo Varis, Traffic ForemanMs Marja-Leena Väisänen, Executive Manager
Central Finland:Ms Seija Ahola, Health InspectorMs Aune Nieminen, Tax OfficialMs Irma Virpikari, Podiatrist
Northern Finland:Ms Eine Heikkilä, Diabetes NurseMs Raija Hyvönen, Practical NurseMs Raija Mäkelä, Financial ManagerMr Ensio Räihä, Engineer
Education
Chairperson:Dr Pirjo Ilanne-Parikka, Internist
Secretary:Ms Outi Himanen, Nurse Educator
Ms Liisa Heinonen, NutritionistMs Liisa Hiltunen, Research FellowDr Jouko Hänninen, Specialist in Primary CareMr Jukka Marttila, PsychologistMs Paula Nikkanen, Diabetes NurseMs Tuula-Maria Partanen,Teacher in Health Care
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DEHKO 2000-2010
Ms Marja Puomio, Education CoordinatorMs Kristiina Salonen, Diabetes NurseMs Tuula Simell, Senior Research Fellow
Type 2 Diabetes
Chairperson:Professor Hannele Yki-Järvinen
Secretary:Ms Eliina Haapa, Nutritionist
Dr Timo Kohvakka, Medical DirectorMs Leena Kokkonen, Nurse EducatorDr Helena Levänen, Specialist in Primary CareMs Irmeli Liukkonen, Teacher in PodiatryMs Leena Pekkonen, Diabetes NurseMs Leena Ryysy, Assistant Chief PhysicianProfessor Tapani RönnemaaDr Mikko Syvänne, Assistant Professor
Prevention of Type 2 Diabetes
Chairperson:Professor Jaakko Tuomilehto
Secretary:Ms Tarja Sampo, Communications Manager
Dr Johan Eriksson, Assistant ProfessorDr Mikael Fogelholm, Executive DirectorMs Ammi Isokallio, Department ManagerMs Sirkka-Liisa Kudjoi, Diabetes NurseMr Seppo Miilunpalo, Senior Research FellowDr Pertti Mustajoki, Chief PhysicianMs Jaana Lindström, Research AssistantMr Mika Pyykkö. Project ManagerProfessor Aila Rissanen
Type 1 Diabetes
Chairperson:Professor Olli Simell
Secretary:Ms Maija Ojala, Responsible Nurse Educator
Dr Per-Henrik Groop, Assistant ProfessorMs Rauni Häkkinen, Diabetes NurseDr Jorma Komulainen, PediatricianMs Else-Maj Lammi, Diabetes NurseDr Ismo Pirttiniemi, Medical DirectorMs Auli Pölönen, NutritionistDr Kaija Saarelma, Specialist in Primary CareDr Juha Saltevo, InternistDr Sirkku Tulokas, Internist
Diabetes Registries
Chairperson:Professor Sirkka Keinänen-Kiukaanniemi
Secretary:Ms Marja Puomio, Education Coordinator
Dr Carola Grönhagen-Riska, Medical DirectorDr Paula Kemppainen, InternistDr Jorma Lahtela, Assistant ProfessorMr Mikko Nenonen, Development ManagerDr Antti Reunanen, Assistant ProfessorDr Juha Tuominen, Assistant AdministrativeChief PhysicianDr Markku Vähätalo, Specialist in Primary Care
Other Contributors
Lifestyle CounsellingMs Eliina Haapa, NutritionistMs Liisa Heinonen, NutritionistComplications of DiabetesCardiovascular DiseasesDr Mikko Syvänne, Assistant ProfessorNephropathyNephropathy Recommendation by the FinnishDiabetes AssociationRetinopathyProfessor Leila LaatikainenDiabetic NeuropathyProfessor Leo NiskanenFoot ProblemsProfessor Tapani RönnemaaDiabetes and PregnancyProfessor Kari Teramo
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DEHKO 2000-2010
Appendix 1 Assessment Plan of the DEHKO Programme
Appendix 2 St Vincent Programme
Appendix 3 Duties of the Diabetes Working Groups of Hospital Districts
Appendix 4 Role of the Finnish Diabetes Association in the Care System
Appendix 5 Duties of the Physician Responsible for Diabetes Care
Appendix 6 Role and Duties of the Diabetes Nurse
Appendix 7 Duties of the Nutritionist in the Care of People with Diabetes
Appendix 8 Duties of the PodiatristDuties of the Foot-Care Team
Appendix 9 Proposal for Quality Criteria for Education
Appendix 10 Skills Required for the Care of People with Diabetes in Primary Health Care
Appendix 11 Proposal for the Content of the Diabetes Registry
Appendix 12 Recommendations by the Medical Advisory Board of the Finnish DiabetesAssociation and the Ministry of Social Affairs and Health on the DistributionSelf-Care Equipment and Supplies
Diagrams of Care Chains
Appendix 13 Care Chain of the Person with Type 2 Diabetes
Appendix 14 Care Chain of the Person with Type 1 Diabetes (Children and Young People)
Appendix 15 Care Chain of the Person with Type 1 Diabetes (Adults)
Appendix 16 Diabetic Complications, Foot Problems
17. Appendixes
65
DEHKO 2000-2010
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66
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ard
ofth
e Fi
nnish
Diab
etes
Ass
ociat
ion
•di
stri
butio
n of
the
rep
ort
to t
he p
artie
s in
volv
ed a
ndco
oper
atin
g pa
r tne
rs•
St V
ince
nt P
rogr
amm
e•
IDF
•W
HO
Phas
e I f
inan
ces
•se
lf-as
sess
men
t•
prog
ram
me
acco
unts
““
Coo
pera
tive
rela
tions
hips
•se
lf-as
sess
men
t•
num
ber,
qual
ity a
nd r
esul
tsof
con
tact
s“
“
Exte
rnal
com
mun
icat
ions
•se
lf-as
sess
men
t•
pres
s cl
ippi
ngs
•bu
lletin
s•
publ
icat
ions
““
Publ
ishe
d ac
tion
prog
ram
me
•ou
tsid
e as
sess
men
t•
prin
ted
actio
n pr
ogra
mm
e“
“
findi
ngs
publ
ishe
d
67
DEHKO 2000-2010
App
endi
x 1
(3) A
SSES
SMEN
T O
F PH
ASE
II /
DIS
SEM
INA T
ION
OF
INFO
RM
ATIO
N, T
RA
ININ
G A
ND
MA
RK
ETIN
G R
ELAT
ED T
O T
HE
AC
TIO
N P
ROG
RA
MM
E
Ass
essm
ent
peri
od:
2/20
00–1
2/20
00T
ime
of a
sses
smen
t:1–
3/20
01
OBJ
ECT
OF
ASS
ESSM
ENT
MET
HO
D O
F A
SSES
SMEN
T
DAT
A O
UT
PUT
AC
TIO
N
In-h
ouse
ope
ratio
ns b
y th
eFi
nnis
h D
iabe
tes A
ssoc
iatio
n•
self-
asse
ssm
ent
•do
cum
ents
pro
duce
d in
the
proc
ess
of im
plem
enta
tion
•pr
oces
sing
of t
he p
rogr
amm
ein
the
adm
inist
ratio
n an
dm
anag
emen
t of t
he a
ssoc
iatio
n•
mee
ting
of t
he d
iabe
tes
wor
king
gro
ups
of t
heho
spita
l dis
tric
ts
Ass
essm
ent
Rep
ort
for
Phas
e II
(Eng
lish
Sum
mar
y)
•Su
b-C
omm
ittee
on
Car
dio-
vasc
ular
Dise
ases
and
Dia
bete
s•
Boar
d of
the
Fin
nish
Dia
bete
sA
ssoc
iatio
n•
Med
ical
Adv
isor
y Bo
ard
of t
heFi
nnis
h D
iabe
tes A
ssoc
iatio
n•
dist
ribu
tion
of t
he r
epor
t to
the
part
ies
invo
lved
and
coop
erat
ing
par t
ners
•St
Vin
cent
Pro
gram
me
•ID
F•
WH
Ofin
ding
s pu
blis
hed
Coo
pera
tive
rela
tions
hips
•se
lf-as
sess
men
t•
num
ber,
qual
ity a
nd r
esul
ts o
fco
ntac
ts“
“
Exte
rnal
com
mun
icat
ions
•se
lf-as
sess
men
t•
pres
s cl
ippi
ngs
•bu
lletin
s•
publ
icat
ions
““
Dev
elop
men
t of
org
aniz
atio
nal
activ
ities
of t
he F
inni
shD
iabe
tes A
ssoc
iatio
n
•se
lf-as
sess
men
t•
activ
ities
and
mat
eria
lpr
oduc
ed fo
r lo
cal b
ranc
hes
•qu
estio
nnai
re t
o lo
cal
bran
ches
““
Phas
e II
finan
ces
•se
lf-as
sess
men
t•
prog
ram
me
acco
unts
““
68
DEHKO 2000-2010
App
endi
x 1
(4) A
SSES
SMEN
T O
F PH
ASE
III /
CA
MPA
IGN
FO
R T
HE
PREV
ENT
ION
OF
TY
PE 2
DIA
BET
ES A
ND
FU
RTH
ER A
CT
ION
Ass
essm
ent
peri
od:
11/2
000–
12/2
001
Tim
e of
ass
essm
ent:
1–3/
2002
O
BJEC
T O
F A
SSES
SMEN
TM
ETH
OD
OF
ASS
ESSM
ENT
DAT
A O
UT
PUT
AC
TIO
N
In-h
ouse
ope
ratio
ns b
y th
eFi
nnis
h D
iabe
tes A
ssoc
iatio
n•
self-
asse
ssm
ent
•do
cum
ents
pro
duce
d in
the
proc
ess
of im
plem
enta
tion
•pr
oces
sing
of t
he p
rogr
amm
ein
the
adm
inis
trat
ion
and
man
agem
ent o
f the
ass
ocia
tion
•m
eetin
g of
the
dia
bete
sw
orki
ng g
roup
s of
the
hosp
ital
dist
rict
s
Ass
essm
ent
Rep
ort
for
Phas
e III
(Eng
lish
Sum
mar
y)
•Su
b-C
omm
ittee
on
Car
dio-
vasc
ular
Dis
ease
s an
d D
iabe
tes
•Bo
ard
of t
he F
inni
sh D
iabe
tes
Ass
ocia
tion
•M
edic
al A
dvis
ory
Boar
d of
the
Finn
ish
Dia
bete
s Ass
ocia
tion
•di
stri
butio
n of
the
rep
ort
toth
e pa
rtie
s in
volv
ed a
ndco
oper
atin
g pa
r tne
rs•
St V
ince
nt P
rogr
amm
e•
IDF
•W
HO
findi
ngs
publ
ishe
d
Coo
pera
tive
rela
tions
hips
•se
lf-as
sess
men
t•
num
ber,
qual
ity a
nd r
esul
ts o
fco
ntac
ts“
“
Exte
rnal
com
mun
icat
ions
•se
lf-as
sess
men
t•
pres
s cl
ippi
ngs
•bu
lletin
s•
publ
icat
ions
““
Dev
elop
men
t of
org
aniz
atio
nal
activ
ities
of t
he F
inni
shD
iabe
tes A
ssoc
iatio
n
•se
lf-as
sess
men
t•
activ
ities
and
mat
eria
lpr
oduc
ed fo
r lo
cal b
ranc
hes
•qu
estio
nnai
re t
o lo
cal b
ranc
hes
““
Phas
e III
fina
nces
•se
lf-as
sess
men
t•
prog
ram
me
acco
unts
““
69
DEHKO 2000-2010
App
endi
x 1
(5)
OV
ERA
LL A
SSES
SMEN
T O
F T
HE
PRO
GR
AM
ME
Ass
essm
ent
peri
od:
1998
–200
1T
ime
of a
sses
smen
t:1–
5/20
02
O
BJEC
T O
F A
SSES
SMEN
TM
ETH
OD
OF
ASS
ESSM
ENT
DAT
A
OU
TPU
T
A
CT
ION
Plan
ning
of t
he p
rogr
amm
e•
outs
ide
asse
ssm
ent
•A
sses
smen
t R
epor
ts fo
rPh
ases
I, II
and
III
•w
ritt
en d
ocum
ents
conc
erni
ng t
he p
rogr
amm
e•
ques
tionn
aire
, inte
rvie
ws,
disc
ussi
ons
Fina
l Rep
ort
for
the
Prog
ram
me
of 1
998–
2002
and
furt
her
actio
n fo
r 20
03–
2010
(En
glis
h ve
rsio
n)
•Su
b-C
omm
ittee
on
Car
dio-
vasc
ular
Dise
ases
and
Dia
bete
s•
Boar
d of
the
Fin
nish
Dia
bete
sA
ssoc
iatio
n•
Med
ical
Adv
isor
y Bo
ard
of t
heFi
nnis
h D
iabe
tes A
ssoc
iatio
n•
dist
ribu
tion
of t
he r
epor
t to
the
part
ies
invo
lved
and
coop
erat
ing
par t
ners
•St
Vin
cent
Pro
gram
me
•ID
F•
WH
Ofin
ding
s pu
blis
hed
Impl
emen
tatio
n of
the
prog
ram
me
(incl
udin
g ex
tern
alco
mm
unic
atio
ns, t
rain
ing,
coop
erat
ive
rela
tions
hips
, etc
)
•ou
tsid
e as
sess
men
t•
Ass
essm
ent
Rep
orts
for
Phas
es I,
II a
nd II
I•
writ
ten
docu
men
ts c
once
rnin
gth
e pr
ogra
mm
e•
ques
tionn
aire
, inte
rvie
ws,
disc
ussi
ons
““
Prog
ram
me
finan
ces
•ou
tsid
e as
sess
men
t•
Ass
essm
ent
Rep
orts
for
Phas
es I,
II a
nd II
I•
final
acc
ount
s an
dac
coun
ting
mat
eria
l
““
70
DEHKO 2000-2010
App
endi
x 1
(6) A
SSES
SMEN
T O
F T
HE
EFFE
CT
IVEN
ESS
OF
TH
E A
CT
ION
PRO
GR
AM
ME
I
Ass
essm
ent
peri
od:
1998
–200
1T
ime
of a
sses
smen
t:1–
5/20
02
OBJ
ECT
OF
ASS
ESSM
ENT
MET
HO
D O
F A
SSES
SMEN
TD
ATA
OU
TPU
TA
CT
ION
Leve
l of a
war
enes
s of
the
ris
k of
typ
e 2
diab
etes
am
ong
the
gene
ral p
opul
atio
n•
Gal
lup
poll
•po
ll da
tast
udy
repo
rtin
clus
ion
in fi
nal r
epor
t
Org
aniz
atio
n of
dia
bete
s ca
re in
the
heal
th-c
are
syst
em•
case
stu
dy•
com
pari
son
with
the
asse
ssm
ent
at b
asel
ine
•ca
se d
ata
case
stu
dy r
epor
tin
clus
ion
in fi
nal r
epor
t
Nat
iona
l sys
tem
of m
onito
ring
car
e•
self-
asse
ssm
ent
•an
alys
is o
f situ
atio
nre
port
incl
usio
n in
fina
l rep
ort
Aw
aren
ess
amon
g th
e he
alth
-car
epe
rson
nel o
f dia
bete
s, th
e pr
ogra
mm
ean
d re
late
d pu
blic
ized
mat
eria
l
•qu
estio
nnai
re a
ndin
terv
iew
•qu
estio
nnai
re a
ndin
terv
iew
dat
are
port
incl
usio
n in
fina
l rep
ort
Dev
elop
men
t of
the
loca
l and
reg
iona
lac
tiviti
es o
f the
Fin
nish
Dia
bete
sA
ssoc
iatio
n
•se
lf-as
sess
men
t•
docu
men
ts o
n lo
cal a
ndor
gani
zatio
nal a
ctiv
ities
•an
nual
rep
orts
•m
onito
ring
by
regi
onal
secr
etar
ies
repo
rtin
clus
ion
in fi
nal r
epor
t
Aw
aren
ess
amon
g th
e m
embe
rs o
f the
Finn
ish
Dia
bete
s Ass
ocia
tion
of t
hepr
ogra
mm
e an
d th
eir
own
view
s ab
out
its im
pact
on
thei
r w
ell-b
eing
•qu
estio
nnai
re•
ques
tionn
aire
dat
are
port
incl
usio
n in
fina
l rep
ort
Rec
omm
enda
tions
of t
he a
ctio
npr
ogra
mm
e•
self-
asse
ssm
ent
•re
com
men
datio
ns o
f the
actio
n pr
ogra
mm
e an
dle
vel o
f ado
ptio
n
repo
rtin
clus
ion
in fi
nal r
epor
t
Dia
bete
s ca
re in
Fin
land
•re
view
of o
ther
res
earc
hin
200
0–20
05 o
n di
abet
esca
re, i
ts r
esul
ts a
nd t
heca
re o
rgan
izat
ion
in F
inla
nd•
com
pari
son
with
stu
dies
and
revi
ews
with
inD
EHKO
•ot
her
rese
arch
revi
ew r
epor
t an
dco
mpa
riso
n re
port
findi
ngs
publ
ishe
d
71
DEHKO 2000-2010
App
endi
x 1
(7) A
SSES
SMEN
T O
F T
HE
EFFE
CT
IVEN
ESS
OF
TH
E A
CT
ION
PRO
GR
AM
ME
II
Ass
essm
ent
peri
od:
chan
ges
betw
een
the
cros
s-se
ctio
nal s
tudi
es o
f 200
0 an
d 20
05T
ime
of a
sses
smen
t:20
05
OBJ
ECT
OF
ASS
ESSM
ENT
MET
HO
D O
F A
SSES
SMEN
TD
ATA
OU
TPU
T
Leve
l of s
atis
fact
ion
of F
inni
shpe
ople
with
dia
bete
s w
ith t
heca
r e t
hey
r ece
ive;
qua
lity
ofse
lf-ca
r e
•qu
estio
nnai
re a
nd/o
rin
terv
iew
stu
dy•
the
data
ar e
col
lect
ed u
sing
an in
tern
atio
nally
com
para
ble
mod
el•
data
from
200
0 an
d 20
05
stud
y re
port
findi
ngs
publ
ishe
d
Org
aniz
atio
n of
dia
bete
s ca
rein
the
hea
lth-c
are
syst
em•
case
stu
dy•
case
stu
dy d
ata
from
200
0an
d 20
05ca
se s
tudy
rep
ort
findi
ngs
publ
ishe
d
Gly
cem
ic c
ontr
ol o
f Fin
nish
peop
le w
ith d
iabe
tes
•re
petit
ion
of c
ross
-se
ctio
nal s
tudy
on
the
glyc
emic
con
trol
of
peop
le w
ith d
iabe
tes
•da
ta fr
om 1
994,
200
0 an
d20
05st
udy
repo
rtfin
ding
s pu
blis
hed
Prev
alen
ce o
f dia
bete
s-re
late
dco
mpl
icat
ions
•cr
oss-
sect
iona
l stu
dy•
exis
ting
regi
stry
and
res
earc
hda
ta•
data
from
200
0 an
d 20
05
stud
y re
port
findi
ngs
publ
ishe
d
AC
TIO
N
72
DEHKO 2000-2010
App
endi
x 2 ST. Vincent Programme
St.Vincent Declaration: Into the 21st Century • Special Edition • Diabetes Voice • Volume 45, September 2000.
A Diabetes Programme in ActionDelice Gan
he St Vincent Declaration was born ofthe belief that action had to be taken to
tackle the growing human and economicburden of diabetes in Europe. The Declaration,signed in St Vincent, Italy, in 1989, was the result ofa joint initiative of the European Region of the In-ternational Diabetes Federation and the EuropeanRegional Office of the World Health Organization(WHO/Euro).
The vision that brought the St Vincent Declarationto life encompassed the fundamental recognition thatthe major players in the healthcare sector had a com-mon interest in the promotion of quality diabetescare. As a result, the first meeting brought togetherpeople with diabetes, healthcare professionals, diabe-tes associations, governments and related industry.This approach also ensured the support of diabetesorganizations and governments in the implementa-tion of national programmes to fulfil the objectives ofthe Declaration. The St Vincent Declaration has be-come the framework upon which diabetes care policiesand strategies have subsequently been based in mostEuropean countries.
The Declaration contained two primary goals and10 target areas which sought to improve the qualityof life of people with diabetes. The specific targetsincluded:
❏ improving the detection and control of diabetes;
❏ raising public awareness of the opportunities ofprevention of diabetes and its complications;
❏ promoting of self-care for people with diabetes;
❏ ensuring that care of children with diabetes isprovided by specialist teams, and that their fami-lies are given the necessary support;
❏ supporting centres of excellence in diabetes care,education and research;
❏ promoting the independence of people with diabetes;
❏ removing discrimination against people with diabetes;
❏ reducing diabetes complications such as blindness,kidney disease and amputations;
❏ setting up information systems to enable healthservicesto monitor and control the quality of healthcare; and
❏ promoting international collaboration.
Recent surveys suggest that the principles of the St
Vincent Declaration are as valid today as they were
in 1989. Nonetheless, the success and widening of
interest for this initiative require an evolution of its
structure and targets as reiterated in the IstanbulCommitment.
T
73
DEHKO 2000-2010
App
endi
x 3Duties of the Diabetes Working Groups
of Hospital Districts
• Improvement and coordination of diabetes care within each hospital district
• Setting of care objectives
• Monitoring and assessment of the health outcomes
• Participation in the development and maintenance of the regional diabetes registry
• Improvement of cooperation between primary health care and specialized medical care
• Harmonization and monitoring of the distribution of self-care equipment
• Arrangement of regional training for care personnel
• Assessment of the need for resources and issuing of guideline recommendations(personnel, equipment, etc)
• Lobbying with regard to medical and political decisions concerning diabetes
74
DEHKO 2000-2010
App
endi
x 4 Role of the Finnish Diabetes Association
in the Care System
HAVING NATIONAL INFLUENCE
1. The Finnish Diabetes Association acts as an advocate for people with diabetes at the national level forthe improvement of diabetes care.
2. It is the task of the Finnish Diabetes Association to promote public awareness and knowledge of diabetesand participate in the public debate on diabetes issues.
3. The Medical Advisory Board and other expert groups of the Finnish Diabetes Association issuerecommendations on diabetes care.
4. The main function of the Association’s the Diabetes Centre is to act as a centre of expertise on theeducation of people with diabetes.
DIABETES EDUCATION OF CARE PERSONNEL AND SELF-CARE TRAINING FOR PEOPLE WITH DIABETES
5. The Diabetes Centre arranges national diabetes courses (self-care training) for people with diabetesof all ages, as well as their immediate family.
6. The Diabetes Centre arranges multidisciplinary education on diabetes care and patient education to allprofessional groups and care teams involved in the care of people with diabetes. This also includes tailoredtraining programmes and consultation activities that may take place right in the care unit.
COMMUNICATIONS AND PUBLISHING ACTIVITIES
7. The Finnish Diabetes Association publishes journals and newsletters and produces material to support goodcare and education for people with diabetes and their family and friends, as well as for professionals andstudents in the health-care and nutrition sectors. In addition, material for people who belong to the riskgroups for type 2 diabetes is provided.
8. Through its public relations activities, the Finnish Diabetes Association strives for better diabetes awarenessamong both the general public and the key groups of decision makers in health care. The Association isresponsible for the national information campaigns on the prevention of type 2 diabetes.
IMPROVING THE QUALITY OF DIABETES CARE
9. The Finnish Diabetes Association participates in improving the quality of diabetes care for instance byconducting a survey on the conditions for setting up a national diabetes registry.
10. The Association will establish a prize that is awarded annually to a unit of primary health care that hasexcelled in the development/effectiveness/quality of diabetes care. The prize will include a monetary award.
ORGANIZATIONAL ACTIVITIES
11. The 108 local branches of the Finnish Diabetes Association are a major resource in supporting the self-care of people with diabetes. Versatile development of the cooperation between the local branches andthe health-care system is one of the Finnish Diabetes Association’s main goals.
12. At the regional level, the five regional committees and regional secretaries of the Finnish DiabetesAssociation provide support to both the health-care system and the local branches of the Association.
13. People with diabetes are represented in the diabetes working groups of each hospital district.
75
DEHKO 2000-2010
App
endi
x 5Duties of the Physician Responsible for Diabetes
Care in the Primary Health-Care System
Together with the diabetes physician of a central hospital:
• to be responsible for planning diabetes care
• to participate in organizing training for professionals at the regional level
• to acts as the link in quality assessment
• to distribute information in his/her own care unit about the general diabetes-related issues of the central hospital
Together with a diabetes nurse:
• to maintain the diabetes registry of the care unit (in the way recommended in this action programme)
• to be responsible for the quality of diabetes care in his/her own health-care centre
• to make development proposals for improving the care of people with diabetes
• to motivate health-care staff to provide good and high-quality care
• to arrange group education for people with diabetes
Duties of the Physician Responsiblefor Diabetes Care in a Large Unit andin the Specialized Health-Care System
There may be several physicians responsible for diabetes care, eg one in each line of activity.
• to oversee the care programme
• to assesses the the care chain for the person with diabetes (quality tools)
• to arrange the regular meetings of the diabetes team and maintain team spirit
• to ensure adequate facilities for diabetes care in the other units of his/her institution or organization
• to compile diabetes-related statistics
• to promote diabetes care in the planning of activities and financial planning and act as an expert in thepreparation of procurement decisions
• to be a member of the diabetes working group of the hospital district
76
DEHKO 2000-2010
App
endi
x 6
Role
and
Dut
ies
of a
Dia
bete
s N
urse
Res
pons
ibili
ties
on
unit
leve
l, su
ch a
s:•
coor
dina
ting
diab
etes
car
e in
the
uni
t•
mai
nten
ance
of d
iabe
tes
regi
str y
, qua
lity
cont
rol o
f car
e•
activ
ities
of t
he d
iabe
tes
team
• im
prov
emen
t of
dia
bete
s ca
re in
his
/her
ow
n un
itTr
aini
ng a
nd p
ublic
rel
atio
ns, s
uch
as:
•tr
aini
ng o
f oth
er s
taff
•pr
omot
ing
awar
enes
s am
ong
the
popu
latio
n ab
out
diab
etes
and
its c
onse
quen
ces
Coo
pera
tion
, suc
h as
:•
mai
ntai
ning
con
tact
s w
ith o
ther
org
aniz
atio
ns t
hat
prov
ide
diab
etes
car
e an
d w
ith lo
cal b
ranc
hes
of t
he F
inni
sh D
iabe
tes
Ass
ocia
tion
•co
oper
atio
n w
ith t
he s
ocia
l ser
vice
•m
aint
aini
ng c
onta
ct w
ith t
he d
iabe
tes
wor
king
gro
up o
f the
hosp
ital d
istr
ict
•de
velo
ping
mul
tipro
fess
iona
l coo
pera
tion
Con
sult
atio
n ac
tivi
ties
, suc
h as
:•
arra
ngin
g ph
one
cons
ulta
tion
for
patie
nts
•ar
rang
ing
cons
ulta
tion
poss
ibili
ties
for
the
staf
f of h
ospi
tal
war
ds, o
ccup
atio
nal h
ealth
car
e, h
ome
nurs
ing
and
hom
ehe
lp s
ervi
ces
Edu
cati
on, s
uch
as:
•in
divi
dual
bas
ic a
nd fu
rthe
r ed
ucat
ion
of p
atie
nts
•or
gani
zing
furt
her
educ
atio
n an
d ap
poin
tmen
ts fo
r di
abet
icpa
tient
s w
ho a
re t
rans
ferr
ed fr
om s
peci
aliz
ed m
edic
al c
are
to p
rim
ary
heal
th c
are
POST
OPE
RAT
IVE
LEV
ELK
EY R
OLE
DU
TIE
SU
SE O
F W
OR
KIN
G T
IME
Dia
bete
s N
urse
unit
of s
peci
aliz
edm
edic
al c
are,
hea
lth-
car e
cen
tre,
outp
atie
nt c
linic
,ho
spita
l war
d
resp
onsi
bilit
y at
uni
tle
vel, c
oord
inat
or,
trai
ning
of o
ther
heal
th-c
are
staf
f,ed
ucat
ion
full-
time
orpa
rt-t
ime
77
DEHKO 2000-2010
Nur
se R
espo
nsib
lefo
r D
iabe
tes
Car
ehe
alth
-car
e ce
ntre
with
pop
ulat
ion-
base
d re
spon
sibi
lity
resp
onsi
bilit
y on
uni
tle
vel, c
oord
inat
or,
trai
ning
of o
ther
heal
th-c
are
staf
f,ed
ucat
ion
Edu
cati
on, s
uch
as:
•in
divi
dual
bas
ic a
nd fu
r the
r ed
ucat
ion
of p
atie
nts
•or
gani
zing
furt
her
educ
atio
n an
d a p
poin
tmen
ts fo
r di
abet
icpa
tient
s w
ho a
re t
rans
ferr
ed fr
om s
peci
aliz
ed m
edic
al c
are
to p
rim
ary
heal
th c
are
Con
sult
atio
n ac
tivi
ties
, suc
h as
:•
phon
e co
nsul
tatio
n w
ith p
atie
nts
•ar
rang
ing
his/
her
own
cons
ulta
tion
chan
nels
Coo
pera
tion
, suc
h as
:•
mai
ntai
ning
con
tact
s w
ith o
ther
org
aniz
atio
ns t
hat
prov
ide
diab
etes
car
e an
d w
ith lo
cal b
ranc
hes
of t
he F
inni
sh D
iabe
tes
Ass
ocia
tion
•co
oper
atio
n w
ith t
he s
ocia
l ser
vice
•de
velo
ping
mul
tipro
fess
iona
l coo
pera
tion
Hea
lth
educ
atio
n, s
uch
as:
•pr
omot
ing
awar
enes
s am
ong
the
popu
latio
n ab
out
diab
etes
and
its e
ffect
s
full-
time
orpa
rt-t
ime
Nur
se w
ithPo
pula
tion-
Base
dR
espo
nsib
ility
heal
th-c
are
cent
resu
buni
t w
ithpo
pula
tion-
base
dre
spon
sibi
lity
educ
atio
nE
duca
tion
, suc
h as
:•
indi
vidu
al b
asic
and
furt
her
educ
atio
n of
pat
ient
sC
onsu
ltat
ion
acti
viti
es, s
uch
as:
•ph
one
cons
ulta
tion
with
pat
ient
s•
arra
ngin
g hi
s/he
r ow
n co
nsul
tatio
n ch
anne
lsP
reve
ntat
ive
mea
sure
s at
pop
ulat
ion
leve
l•
plan
ning
and
impl
emen
tatio
nC
oope
rati
on, s
uch
as:
•co
oper
atio
n w
ith t
he s
ocia
l ser
vice
•de
velo
ping
mul
tipro
fess
iona
l coo
pera
tion
part
of w
orki
ng t
ime
Oth
er n
urse
sow
n ca
re u
nit
part
icip
atio
n in
the
care
of p
eopl
e w
ithdi
abet
es
Dia
bete
s ca
re in
con
junc
tion
with
the
man
agem
ent
of o
ther
heal
th p
robl
ems
smal
l par
t of
wor
king
tim
e
A d
iabe
tes
nurs
e is
a n
urse
spe
cial
ly s
elf-e
duca
ted
and
form
ally
tra
ined
in d
iabe
tes
care
and
em
ploy
ed a
t a
cent
ral h
ospi
tal,
heal
th-c
are
cent
re, o
utpa
tient
clin
icor
hos
pita
l dep
artm
ent.
A n
urse
res
pons
ible
for
diab
etes
car
e is
a n
urse
spec
ially
sel
f-edu
cate
d an
d fo
rmal
ly t
rain
ed in
dia
-be
tes
care
and
em
ploy
ed a
t a
heal
th-c
are
cent
rew
ith p
opul
atio
n-ba
sed
or lo
cal r
espo
nsib
ility
.
The
se t
wo
type
s of
nur
ses
have
sim
ilar
k ey
role
san
d jo
b de
scri
ptio
ns. I
t is
impo
r tan
t to
app
oint
adi
abet
es n
urse
or
a nu
rse
resp
onsi
ble
for
diab
e-te
s ca
re t
o ea
ch h
ealth
-car
e un
it.
78
DEHKO 2000-2010
App
endi
x 7 Duties of the Nutritionist in the Care
of People with Diabetes
Primary Health Care:
• to be a member of the diabetes team
• to train and provide consultation to other staff
• to educate people newly diagnosed with type 1 diabetes
• to educate people with type 1 or type 2 diabetes in situations that require specialist know-how of nutritionaltherapy (see pages 26–27) and Nutritional Recommendations of the Finnish Diabetes Association 1999), if notundertaken by specialized medical care
• to act as an expert in nutritional therapy for diabetes:
• in organizing nutritional therapy for diabetes in his/her own area and own care unit
• in planning meals at school and work
• in the care of old people
• in planning meals in other institutional settings
• to update and monitor the educational material used in nutritional education
• to participate in the planning and implementation of projects aimed at the prevention of diabetes
• to participate in improving and monitoring the quality of nutritional therapy in his/her own health-carecentre/area
Specialized Medical Care:
• to be a member of the diabetes team
• to educate people newly diagnosed with type 1 diabetes
• to participate in monitoring the care of children with diabetes
• to educate people with type 1 or type 2 diabetes in situations that require specialist know-howof nutritional therapy (see pages 26–27)
• to train and provide consultation to other staff
• to act as an expert in nutritional therapy for diabetes:
• in organizing nutritional therapy for diabetes in his/her own area and own care unit and in hospital wardsand outpatient clinics
• in developing meal services in cooperation with catering organizations
• to update and monitor the educational material used in nutritional education
• to participate in improving and monitoring the quality of nutritional therapy in his/her own hospital/area
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endi
x 8Duties of the Podiatrist in the Care
of a Person with Diabetes
• to act as an expert in foot care in the diabetes team
• to educate and encourage clients in the self-care of the feet both individually and in groups
• to be responsible for high-quality foot care, including management of skin and nail problemsand treatment of ulcers
• to provide preventative and maintenance care in the form of off-loading (shoe inlays and toe shields)
• to guide and encourage clients to exercise and, together with a physical therapist, provide preventative andfunction-maintaining care of the lower limbs, mobility aids and footwear
• to provide footwear therapy (therapeutic shoes and individually made special footwear) in cooperation withan orthotist-prosthetist and appliance manufacturers
• to prepare digital prostheses, participate as a member of a team in fitting lower-limb prostheses and provideexercise education
• to train and instruct personnel within health care and the social service
• to develop the speciality of foot care and to promote the foot care of people with diabetes in his/her ownunit/area according to the patients’ risk classification
In the primary health-care system, the emphasis is on preventative activities, basic education on self-care of thefeet, screening for feet at risk, and implementation of foot care according to the patients’ risk classification incooperation with home nursing and specialized medical care, as well as training of other personnel. In the carechain, the primary health-care system also undertakes to monitor patients transferred from specialized medicalcare.
In specialized medical care, the focus is on the care of severe foot problems, rapid availability of consultation,arrangement of further care and patient monitoring together with the primary health-care system and homenursing, as well as the improvement of foot care at the regional level in cooperation with the diabetes workinggroup.
Duties of the Foot-Care Team
• Preventative activities: education, guidance, training, screening for and follow up of patients at risk
• Provision of consultation: low consultation threshold, regular meetings at short intervals
• Examinations and care: multidisciplinary and multiprofessional management of each patient, targeting andcoordination of care, referrals for care and follow up
• Development of a regional system of monitoring foot care and arrangement of quality control
80
DEHKO 2000-2010
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endi
x 9 Proposal for Quality Criteria for Education
Outcome criteria reflect changes brought about by education.
1. The person with diabetes will understand, depending on his/her individual capabilities, how diabetes affectshis/her body and the significance of maintaining a healthy lifestyle:• He/she will be able to describe the basics concerning his/her own care, as well as the relationships between
diabetes and its complications.• He/she will be able to recognize, prevent and treat potential acute problems (hyperglycemia or
hypoglycemia) and complications that may develop over a longer period of time.
2. The person with diabetes will understand the various options in his/her care and their consequences:• He/she will make choices that promote the achievement of good glycemic control.• In his/her decisions concerning diabetes, he/she will be capable of situation-specific problem-solving.• When necessary, he/she will alter his/her lifestyle to attain better health.
3. The control of the patient’s diabetes will be improved: blood glucose, glycosylated hemoglobin, serum lipid levels, blood pressure, weight.
4. The number of diabetes-related emergency department visits and hospital care days will be reduced.
5. Diabetes-related absences from school or work will be reduced.
6. People with diabetes will know how to utilize health-care services expediently:• Detection of the risk factors for diabetic complications (eg participation in fundus photography)
7. The care unit personnel and patients will be familiar with the risk factors for diabetes and will be aware ofthe means by which it is possible to prevent or delay the development of diabetes and its complications:• Information about factors contributing to the development of diabetes and its complications will bebroadly available.• The care unit personnel and patients will perceive diabetes as a disease.
Structural criteria reflect the resources required for the implementation of education.
1. There will be sufficient and professional human resources to carry out education.
2. There will be premises, an environment and facilities for the implementation of education such as arerequired and support the learning process.
3. Teamwork will be emphasized in the implementation of education.
4. The professional skill of educators will be regularly assessed and enhanced.
Process criteria reflect the practical implementation of education.
1. Education will be based on the expectations of people with diabetes and on a continuous assessment oftheir needs.
2. Education will be client-oriented and based on up-to-date principles of learning and education.
3. Education will be a continuous process carried out in cooperation with the other parties involved in the careof the person with diabetes. The team responsible for the implementation of education will have a commonlyagreed division of labour, congruent aims and a uniform work philosophy.
4. Education will be professional and ethical. It will emphasize a positive attitude to life and interaction on anequal basis.
5. The effectiveness and quality of education will be regularly assessed, and the services will be reviewed asnecessary on the basis of the assessment.
81
DEHKO 2000-2010
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endi
x 10Skills Required for the Care of People
with Diabetes in Primary Health Care
Practical diabetes care
• adoption of a care model that supports the control of diabetes• up-to-date theoretical knowledge
- etiology, clinical presentation, basics of care, development of complications, their clinical picture andprinciples of care
• care and follow up of type 2 diabetes and uncomplicated type 1 diabetes• screening for and detection of complications and their treatment and monitoring in primary health care• understanding of the special features of diabetes in children and management of emergency situations• recognition of the need for expert consultation• self-assessment of one’s own work and assessment of the work of the diabetes team
Education
• the adult as a learner• knowledge of the psychology of lifestyle formation and lifestyle changes• mastery of the client-oriented educational process and motivational interaction that support the management
of diabetes• flexible application of educational methods and tools• assessment of the learning results of the person with diabetes and self-assessment of one’s own educational work
Diabetes and eating
• Nutritional Recommendations of the Finnish Diabetes Association• effects of different nutrients on blood glucose, weight control, blood pressure and blood lipid levels• physiology of weight reduction, psychology of eating behaviour and practical implementation of weight control
education• nutritional history taking and evaluation• education of people with type 2 diabetes on the amount and quality of fats and reduction of energy intake• education of people with type 1 diabetes on adapting their meal rhythm, energy intake, energy consumption
and carbohydrates to insulin activity• identification of needs for special education• special education on losing weight, weight control group, diabetes nurse, nutritionist
Foot care
• knowledge of the mechanism, predisposing factors and prevention of foot problems in diabetes• foot examination and identification of patients at risk• education on self-care of feet, minor foot injuries and cuts and proper footwear• treatment of mycotic infections• recognition of and education on feet at risk• local, antibiotic and off-loading therapy for foot infections in primary health care• recognition of critical ischemia• identification of a need for care and education provided by a podiatrist• identification of a need to consult the foot-care team at the central hospital• postoperative care and follow up of vascular and surgical procedures• arrangement of supply of technical aids
Physical activity
• knowledge of the general health-promoting effects of physical activity• education on weight-loss exercise, health exercise and fitness training• utilization of exercise in the care of type 2 diabetes• adaptation of physical activity to the meals and insulin treatment of people with type 1 diabetes• prevention of hypoglycemia in connection with physical activity• knowledge of the exercise restrictions caused by diabetic complications• education on purchasing and using proper footwear
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DEHKO 2000-2010
App
endi
x 11 Proposal for the Content of the Diabetes Registry
Visit information Care
Date • Insulin year started
Identity code • Nutritional therapy only year started
Municipality code • Oral drug year started
Type of diabetes • Combination therapy year started
Type 1 • Antilipemic drug year started
Type 2 • Antihypertensive drug year started
Gestational diabetes • Aspirin year started
Other
Year of diagnosis Weight, Height -> BMI
Blood pressure
Smoking
Fundus photography/ophthalmoscopy date
■ Biochemical parameters ■ Endpoint events
(most recent value) Year of diagnosis/date of procedure
Date Myocardial infarction/coronary artery bypassgrafting/angioplasty
HbA1c Stroke
Lipids Foot ulcer neuropathic/ischemic
serum total cholesterol Amputation below/above ankle
serum HDL cholesterol Laser treatment/blindness
serum triglycerides Dialysis (starting)
serum LDL cholesterol Death
Microalbuminuria µg/min(or normal/abnormal value)
Proteinuria g/24 h
Creatinine µmol/l
83
DEHKO 2000-2010
App
endi
x 12Demand for Equipment and Supplies for Diabetes Care and Care Monitoring
Recommendation by the Medical Advisory Board of the Finnish Diabetes Association 26 March 1998
For many reasons, the self-monitoring of care has played anincreasingly central role in diabetes care. During the nineties, severalextensive studies have been completed which demonstrate thatgood glycemic control decreases the risk of complications, as wellas delaying the progression of complications. The key to goodglycemic control lies in the self-care of people with diabetes, andthe central objective of diabetes care is therefore to teach peoplewith diabetes to be the best experts on their own disease. Onlythrough their own activity can good health outcomes be achieved.This objective requires the self-monitoring of blood glucose levelsaccording to individual needs. People with diabetes who have good glycemic control and whotake care of themselves well require fewer consultation visits to adoctor. Moreover, the development of electronic communicationalso reduces the number of direct patient-doctor contacts, as ithas become possible to electronically transmit the results of hometests directly to the doctor. The emphasis in diabetes care isincreasingly on outpatient care: the care of a newly diagnosedperson with diabetes, as well as the intensification of the care of aperson who has poor glycemic control, is gradually shifting to
outpatient care. The number of days of care of uncomplicateddiabetes therefore decreases, which is quite likely to result insignificant savings in diabetes care costs. All in all, the cost of self-monitoring the blood glucose level is a minor expense in the overallhealth-care costs caused by diabetes. The recommendations presented below are average guidelines. TheMedical Advisory Board emphasizes the individual nature of the needfor self-monitoring of blood glucose: it may be sufficient for one patientto measure his/her blood glucose once or twice a week, whereas it isnecessary for the well-being of another person to take the test severaltimes each day every day of the year. Exceptions must therefore beallowed in the case of the individual patient in special circumstances(at the beginning of the care, when insulin dosage is altered, duringpregnancy, during sick days or when the nature of the patient’s workso demands) to the recommendations listed below when the attendingphysician deems it necessary. In addition, children with diabetes oftenrequire more frequent monitoring of blood glucose than the averagerecommendations. The need for test equipment for measuring boththe blood glucose and urine glucose can be assessed on the basis of arecord kept of the home tests.
RECOMMENDATIONS
1. Strips for monitoring blood glucose
People with diabetes treated with insulinThe average requirement is 25 strips/week. The need for self-monito-ring varies a great deal on an individual basis, and people with diabe-tes are often the best experts on the need to monitor their owndisease. Children with diabetes, labile insulin-dependent adults andpregnant women with diabetes have a substantially greater than ave-rage need for monitoring. Similarly, in the initial stage of diabetes, theneed for monitoring is greater than average. The patients’ individualneeds must be reasonably taken into account in the supply of strips.
People with diabetes treated with oral agents or nutritional therapyThe average need of people with diabetes treated with oral agentsor nutritional therapy is a maximum of 10 strips/week. In the moni-toring of the blood glucose of people with type 2 diabetes, the ef-fect of the results on the care of the patient should be evaluated. A lancet for taking a blood sample can, in good circumstances,be used several times, provided that the blade is recapped aftereach use.
2. Blood glucose metersBlood glucose meters for long-term use are purchased by the per-son with diabetes himself/herself. However, it should be possibleto borrow meters flexibly in the initial stage of the disease, whenbalancing blood glucose and during pregnancy. Because most ofthe hospitals in Finland have already transferred or are transfer-ring to the system of measuring glucose levels in serum/plasmarather than whole blood, using meters that determine the serum/plasma glucose level should be favoured in the future. The selecti-on of meters should also take into account the increasing use ofPC-based download programs for blood glucose meters.
3. Urine test strips
People with diabetes treated with insulinUrine glucose only needs to be monitored in exceptional cases
where the person with diabetes is not measuring his/her bloodglucose. In these cases, the average requirement is 20 strips/week,and generally strips that measure only the urine glucose are suffi-cient. However, children and labile insulin-dependent adults have agreater need for monitoring. People with diabetes treated with insulin need an average of 50strips for monitoring ketone levels/6 months (the smallest packageavailable for distribution).
People with diabetes treated with oral agents or nutritional therapyThe need for monitoring the urine glucose of people with diabetestreated with oral agents or nutritional therapy is on average 5-10strips/month if they are not measuring their blood glucose.
4. Insulin syringes, pens and needles
In principle, disposable syringes and needles are meant for oneinjection only, but in favourable circumstances they can be usedsafely for 4-6 injections or for 1-3 days. Small children are an ex-ception, and it is recommended that the equipment should only beused once because of injection pain and accuracy of dosage. In thecase of multiple-use insulin pens, one pen is needed for each typeof insulin. All types of insulin pens currently on the market shouldbe available, and a new pen should be given to replace a pen bro-ken in normal use. Generally, there is no need to use wipes to cleanse the skinbefore an injection, but people with diabetes who work in particu-larly dirty conditions or have other reasons to cleanse the skinform an exception. There must be justification from the attendingphysician to obtain skin-cleansing wipes.
Equipment and supplies for insulin pump therapyAccording to the commonly agreed division of duties, the unit thatprovides the care for the person with diabetes purchases and handsout the insulin pump. The need for supplies for an insulin pump(special batteries, belts, cases, infusion supplies, refill ampoules ofinsulin) varies according to individual needs.
84
DEHKO 2000-2010
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endi
x 12
To those mentioned under Distribution below
DELIVERY OF CARE SUPPLIES AND EQUIPMENT BYHEALTH-CARE CENTRES
According to the Public Health Act (66/1992), it is the duty of the municipality to be responsible for public health work.As part of public health work, the municipality must provide medical services for its residents. In accordance with Section2 of the Public Health Act, the Ministry of Social Affairs and Health sends this letter concerning the distribution of caresupplies and equipment to the municipalities and joint municipal authorities that maintain health-care centres. This letterdoes not concern technical aids of which there are separate regulations, for example, in the Public Health Act, the Decreeon Medical Rehabilitation (1015/1991) and the Act on Client Fees in Social and Health-Care Services (734/1992). Thisrecommendation has been drawn up in cooperation with the Association of Finnish Local and Regional Authorities. Inthe process of preparing this recommendation, representatives of certain municipalities and joint municipal authoritiesthat maintain health-care centres have been heard, as well as representatives of patients’ organizations.
The distribution of equipment and supplies for the care and follow up of certain long-term diseases withoutcharge to the patients according to their individual needs is an established part of the medical care provided by health-care centres. Previously, the practice was organized in detail on the basis of letters of instructions issued by the NationalBoard of Health. Since the letters of instructions were rescinded in the early 1990s, health-care centres have generallycontinued to act according to these principles.
A well-functioning distribution of care equipment improves the conditions for patients’ self-care and promotespatients’ commitment to their care, resulting in better health outcomes. Consequently, patients’ ability to work and func-tional capacity improve, as well as the quality of their lives, and the risk of complications and the need for consultationvisits to a physician are reduced. In addition, this has effects with regard to the health-care costs of society.
The Ministry of Social Affairs and Health recommends that the health-care centres maintained by municipalitiesand joint municipal authorities distribute such care equipment and supplies to people with long-term diseases in outpa-tient care as are necessary for the care and monitoring of their disease or its sequelae according to the following princi-ples.
The distribution of supplies and equipment necessary for the care and monitoring of patients’ diseases from ahealth-care centre to the patient must at all times be based on individual need, which is determined by the attendingphysician. The health-care centre physicians decide upon the commencement of distribution.
The distribution is commenced if the need for care supplies and equipment is assessed as being of a long-termnature, in general lasting more than three months. Generally, supplies and equipment to meet the need for three monthsare handed out at a time, and the need for them and whether they are appropriate are always assessed when they arehanded out. Distribution and use are monitored on an individual basis. The equipment will be available at the health-carecentre or is delivered at the home of the patient, for instance in connection with home nursing. The supplies and equip-ment are handed out free of charge, and no deductibles, handling charges or any other fees are to be levied. The Ministryof Social Affairs and Health, as well as the provincial governments, will monitor the implementation of the distributionof care supplies and equipment.
Examples of care supplies and equipment of this type are listed in Appendix 1.
Terttu Huttu-Juntunen, Minister
Pekka Järvinen, Government Counsellor
DISTRIBUTION: Municipalities and joint municipal authorities that maintain health-care centres
FOR INFORMATION: Hospital districts, Helsinki University Central HospitalNational Authority for Medicolegal AffairsProvincial governmentsThe Association of Finnish Local and Regional AuthoritiesChancellor of JusticeParliamentary OmbudsmanParliamentary Committee of Social Affairs and HealthThe National Research and Development Centre for Welfare and Health (STAKES)Association of Voluntary Health, Social and Welfare Organisations
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DEHKO 2000-2010
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endi
x 13
Very high blood glucose and/orsymptoms linked to it (fastingblood glucose above 20 mmol/l
Assessment of overall risk.Lifestyle counselling, preparation for self-careeducation on self-care,monitoring, consideration of drug therapy(glucose/lipids/blood pressure/aspirin)
Treatment and monitoring of diabetes and therisk factors for cardiovascular disease• bedtime (insulin) combination therapy• antilipemic medication• aspirin• antihypertensives
Distribution of care equipment
Investigation of long-term (six months)poor health outcome
Self-care training and early rehabilitation
Diagnosis of diabetes/metabolic syndrome,assessment of the risk of cardiovascular disease
Proper Care Setting
Primary health care, private sector, occupational health care
Department of internal medicine*,inpatient ward of health-care centre,short-term inpatient care
Primary health care,private sector,occupational health care
Primary health care,private sector,occupational health care
Primary health care
Department of internal medicine*,outpatient care as a rule,Diabetes Centre
Diabetes Centre,local branches of the Finnish,Diabetes Association, care units
*central hospital, district hospital, city hospital
Care Chain of a Person withType 2 Diabetes
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DEHKO 2000-2010
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endi
x 14
Primary health care: suspicionof a new case of diabetes
Urgent referral
Diagnosis of diabetes
Treatment of ketoacidosis
Commencement of diabetes care
Education on self-care
Diabetes care and monitoring
Distribution of care equipment
Preventative health care
Transfer to adult diabetes care
Self-care training courses, familycourses, clubs for young people
Proper Care Setting
Pediatrics unit
Pediatric hospital ward orpediatric outpatient clinic
Pediatric hospital ward orpediatric outpatient clinic
Pediatric hospital ward orpediatric outpatient clinic
Unit familiar with diabetes carefor children or young people
Primary health care
Child welfare clinic, maternalhealth centre, school health care
Diabetes Centre and localbranches of the Finnish DiabetesAssociation, hospitals
Department of internal medicineor other unit familiar withdiabetes care
Care Chain of a person with Type 1 Diabetes(Child and Young Person)
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Setting
tal ward oratient clinic
tal ward oratient clinic
tal ward oratient clinic
ith diabetes careyoung people
care
clinic, maternalchool health care
re and local Finnish Diabetes
ospitals
internal medicineamiliar with
Suspicion of a new case of diabetesreferred to a department of internalmedicine* without delay
Diagnosis of diabetes
Treatment of severe ketoacidosis
Commencement of insulintherapy, basic education
Preparation for self-care (basic education),consultation visits for 1–2 years.Transfer to permanent care unit requiresmastery of self-care
Diabetes care and monitoring
Distribution of care equipment
Self-care training course (recommended),self-care support group
Investigation of poor health outcome
Proper Care Setting
Central hospital
Department of internal medicine*
Department of internal medicine*,other unit familiar with diabetes
Primary health-care,private sector,occupational health care
Primary health care
Diabetes Centre, hospitals,primary health care,local branches of the FinnishDiabetes Association
Department of internal medicine*,outpatient care as a rule,Diabetes Centre
*central hospital, district hospital, city hospital
Care Chain of a Person with Type 1Diabetes (Adult)
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App
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App
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Person with diabetes
Changes in the fundus(severe backgroundretinopathy, proliferativeretinopathy, maculopathy)
Coronary heart disease, mildcirculatory problem in lower limbs,hypertension, microalbuminuria
Acute cardiovascular complications(heart, brain, lower limbs), refractorycardiovascular disease, proteinuria*,elevated creatinine**
*urinary protein excretion rate > 3 g/24 h**serum creatinine > 150 mmol/l
Proper Care Setting
Ophthalmology unit
Primary health care,private sector,occupational health care
Department of internal medicine*
*specialized medical care
Diabetes care and monitoring
Minor foot problems
Severe foot problems
Problematic neuropathy, eg aches and pains
Proper Care Setting
Consultation visit with podiatrist
Foot care team within specialized medical care
Neurology unit within specialized medical care,primary health care, private sector
Diabetes Complications
Diabetes-Related Foot Problems
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DEHKO 2000-2010
To Decision Makers and Health-Care Providers
Valle T, Koivisto VA, Reunanen A, Kangas T, Rissanen A. Glycemic control in patients with diabetes in Finland. Dia-betes Care 22:575-579, 1999.
Report of a WHO Consultation. Definition, Diagnosis and Classification of Diabetes Mellitus and its Complica-tions. Part 1: Diagnosis and Classification of Diabetes Mellitus. Geneva 1999.
History of Diabetes Care Arrangements in Finland
Valtion sokeritautitoimikunta: Suunnitelma sokeritaudin hoidon järjestämiseksi Suomessa. [Governmental Diabe-tes Committee: A Plan to Organize Diabetes Care in Finland]. Komiteamietintö 1976:5. Valtion painatuskeskus,Helsinki, 1976.
St. Vincent Declaration. International Diabetes Federation and WHO Regional Office for Europe, 1989.
Kangas T. The Finndiab Report. Health care of people with diabetes in Finland. Stakes, Research Reports 58, 1995.
Costs of Diabetes
Kangas, T, Sivonen, K : Analyses of incremental and total direct costs of health care for persons with diabetesby type of diabetes with age and sex matched controls. Abstracts for the 17th IDF Congress, Mexico. Diabetes,res.clin.pract.2000:50 (suppl):8
Kangas T, Reunanen A, Koivisto VA, et al. Direct costs of health care of drug-treated diabetic patients in Finland in1989. In Kangas (ed.). The Finndiab Report. Stakes, Research Reports 58, 1995.
Cost effectiveness analysis of improved blood pressure control in hypertensive patients with type 2 diabetes.UKPDS 40. UK Prospective Diabetes Study Group. BMJ 317:720-726, 1998.
Herman WH, Alexander CM, Cook JR, Boccuzzi SJ, Musliner TA, Pedersen TR, Kjekshus J, Pyörälä K. Effect ofsimvastatin treatment on cardiovascular resource utilization in impaired fasting glucose and diabetes. Findingsfrom the Scandinavian Simvastatin Survival Study. Diabetes Care 22:1771-1778, 1999.
Ebrahim S, Smith GD, McCabe C, et al. What role for statins? A review and economic model. Health TechnologyAssessment 3(19):1-91, 1999.
Herman WH, Eastman RC. The effects of treatment on the direct costs of diabetes. Diabetes Care 21(suppl3):C19-C24, 1998.
Pajunpää H. Diabeettisen retinopatian valokuvaseulonnan kustannukset ja hyödyt sekä näkövammaisten elämän-laatu ja kuolleisuus [The costs and benefits of screening for diabetic retinopathy by fundus photography and thequality of life and mortality of visually impaired people]. Acta Universitatis Ouluensis D Medica 522, University ofOulu, Oulu 1999.
Jönsson B, et al. The cost-effectiveness of lipid lowering in patients with diabetes: results from the 4S trial. Diabe-tologia 42:1293-1301, 1999.
Goldman L, et al. 27th Bethesda Conference: matching the intensity of risk factor management with the hazardfor coronary disease events. Task Force 6. Cost effectiveness of assessment and management of risk factors. J AmColl Cardiol 27:1020-1030, 1996.
Appendix 18
Setting
it with podiatrist
within specialized medical care
within specialized medical care,care, private sector
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DEHKO 2000-2010
Care: a Part of Life for a Person with Diabetes
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International Consensus Standards of Practice for Diabetes Education. IDF Consultative Section on DiabetesEducation. 1997. In Krans HMJ, Porta M, Keen H, Staehr-Johansen K (eds.). Diabetes Care and Research in Euro-pe. The St Vincent Declaration Action Programme. Implementation document. WHO, 1995.
From Compliance to Empowerment. Improving the Quality of Diabetes Care. The Norwegian Diabetes Associati-on, Norwegian Board of Health, National Nutrition Council, National Institute of Public Health, 1997.
Therapeutic Patient Education. Report of a WHO Working Group. 1998.
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Type 2 Diabetes
Pyörälä K, Pedersen TR, Kjekshus J, Faergeman O, Olsson AG, Thorgeirsson G. Cholesterol lowering with simvas-tatin improves prognosis of diabetic patients with coronary heart disease. A subgroup analysis of the ScandinavianSimvastatin Survival Study (4S). Diabetes Care 20:614-620, 1997.
Goldberg RB, Mellies MJ, Sacks FM, Moye LA, Howard BV, Howard WJ, Davis BR, Cole TG, Pfeffer MA, BraunwaldE. for the CARE Investigators. Cardiovascular events and their reduction with pravastatin in diabetic and glucose-intolerant myocardial infarction survivors with average cholesterol levels. Subgroup analyses in the cholesteroland recurrent events (CARE) trial. Circulation 98:2513-2519, 1998.
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Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2diabetes: UKPDS 39. UK Prospective Diabetes Study Group. BMJ 317:713-720, 1998.
Hansson L, Lindholm LH, Niskanen L, Lanke J, Hedner T, Niklason A, Luomanmaki K, Dahlof B, de Faire U, MorlinC, Karlberg BE, Wester PO, Bjorck JE. Effect of angiotensin-converting-enzyme inhibition compared with conven-tional therapy on cardiovascular morbidity and mortality in hypertension: the Captopril Prevention Project(CAPPP) randomised trial. Lancet 353:611-616, 1999.
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Appendix 18
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Yki-Järvinen H, Ryysy L, Nikkilä K, Tulokas T, Vanamo R, Heikkilä M. Comparison of bedtime insulin regimens inpatients with type 2 diabetes mellitus: a randomized, controlled trial. Ann Intern Med 130: 389-396, 1999.
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ETDRS Investigators. Aspirin effects on mortality and morbidity in patients with diabetes mellitus. JAMA268:1292-1300, 1998.
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Type 1 Diabetes
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Diabetes and Pregnancy
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Complications of Diabetes
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Appendix 18
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Diabetes Registries
Mäkelä M, Lappalainen M, Orre S. Terveydenhuollon erillisrekisterit. Selvitys Suomessa ylläpidettävistä valtakunnal-lisista ja alueellisista potilasrekistereistä. [Specific registries of the health-care system. A review of national andregional patient registries in Finland.] FinOHTA Report 3, 1997.
Orre R, Kiuru S (eds.). Rekistereistä hyvinvointia: Sosiaali- ja terveydenhuollon Rekisteripäivät
8.-9.10.1998 [Well-Being from registries: Registry Seminar for Social Services and Health Care 8-9 October1998]. Stakes, Tilastoraportti 28, 1998.
Nationellt diabetesregister [The National Diabetes Registry]. Socialstyrelsen, Sverige 1997.
Svenska Nationella diabetes registret, preliminär årsrapport 1996 [Preliminary Annual Report for 1996 of theNational Diabetes Registry of Sweden]. Socialstyrelsen, Sverige 1996.
Kangas T. Diabeetikoiden hoito Suomessa: avohoito, sairaalahoito ja hoitotasapaino [The care of people withdiabetes in Finland: outpatient care, hospital care and glycemic control]. Stakes, Research Reports 29, Jyväskylä1993.
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