AN INDIRECT EVALUATION OF THE NATIONAL PROGRAM OF DIABETES MELLITUS STUDY CASE OF ROMANIA

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1 Rev. Med. Chir. Soc. Med. Nat., Iaşi 2013 vol. 117, no. 2 PREVENTIVE MEDICINE - LABORATORY ORIGINAL PAPERS AN INDIRECT EVALUATION OF THE NATIONAL PROGRAM OF DIABETES MELLITUS STUDY CASE OF ROMANIA Maria Liliana Iliescu 1, Dana Teodora Anton 2 University of Medicine and Pharmacy Grigore T. Popa - Iaşi Faculty of Medicine 1. Discipline of Management and Public Health 2. Pediatrics department AN INDIRECT EVALUATION OF THE NATIONAL PROGRAM OF DIABETES MELLITUS STUDY CASE OF ROMANIA (Abstract)Diabetes mellitus (DM) represents an important problem of public health according to the worldwide statistical data. In Romania, the national program is facing the same situation: increasing incidence (both for children and adults) and prevalence of this disease. Aim: To evaluate the results of the national program for DM through some indirect indicators. Material and methods: This study represents a descriptive analysis of hospitalized DM cases between and , in Romania. The lack of statistical data available from the Ministry of Public Health (the latest update on the web page for DM is from 2007) makes the evaluation of the outcomes of this program quite difficult. An indirect evaluation is possible using the national hospital regi s- trations for DM complications, recorded by the National School of Management and Public Health. For diagnostic registration was used the classification for Diagnostic Related Group (DRG), version HCFA DRG v. 18.Results: Despite the facilities offered to diabetic patients through the program, the burden of DM over the health system is quite large due to the large number of patients having complications. Conclusions: Even the objectives of the program appear to be accomplished; the indirect outcomes of the evaluation suggest that could be a gap between the hospital specialist and family doctors and a lack of health education for patients with DM. Keywords: DIABETES MELLITUS, NATIONAL PROGRAM, EVALUA- TION, HOSPITAL, FAMILY DOCTOR. Diabetes mellitus (DM) represents an important problem of public health according to the worldwide statistical data, the World Health Organization (WHO) describing this as the chronic disease epidemic of this century. According to Diabetes Commission from Ministry of Public Health, in Romania are actually registered 800,000 diabetic patients, more than 600,000 having neuropathy due to the disease. Incidence and prevalence of diabetes mellitus (DM) are increasing in Europe and, as well, in Romania. The 5th edition of IDF Diabetes Atlas estimates that the prevalence rate in 2011 was 9.2% of the adult population (almost 1,506,300 people) and will rise up to 11.1% in 2030 (1). The latest WHO data published in April 2011 shows that DM deaths in Romania reached 2,203 or 1.02% of total deaths. The age adjusted death rate is 6.29 per 100,000 of population, ranking 483

2 Maria Liliana Iliescu, Dana Teodora Anton Romania on the 179 th place in the world (2). The incidence of childhood onset type 1 diabetes is increasing in many countries in the world, with geographic differences in trends within Europe with an overall annual increase estimated around 3%. There is also good evidence to suggest that, in relative terms, increases are greatest in young children (1). The treatment for diabetic patients is free of charge, due to the National program for DM. According to the latest legislation, the cost for the treatment will be supported by the Insurance Houses at the national and local levels. The national health programs represent, according to Health Reform Law no. 95/2006, a set of multi-annual actions, in order to evaluate, prevent, treat and control the diseases having a population health status major impact (3). The program for DM is one of them. The aim of this program is to improve the health status of diabetic patients and to increase life span through the access to specific treatment. The objectives are as follows: prevention and control for diabetes and other nutrition diseases; treatment with insulin for diabetic patients; treatment with oral antihyperglycemic agents. The activities included are referring at: information, education, communication and training for the personnel involved in the program; periodically and annually evaluation for damage blood vessels and glycosylated hemoglobin HbA1c; insuring the self-monitoring for insulin-treated patients; facilitating the access to some special treatments, such as insulin pumps or special shoes, in certain cases; implementing the National Register for Diabetes. The coordination of the program is ensured by the General department for policies, strategies and health quality management. The Institute for Diabetes, Nutrition and Metabolic Diseases (located in Bucharest) is responsible for technical coordination. MATERIAL AND METHODS The evaluation of the DM national health program results through some indirect indicators is a descriptive analysis of hospitalized DM cases between and in Romania. The lack of statistical data available from the Ministry of Public Health (the latest update on the web page for DM is from 2007) makes the evaluation of the outcomes of this program quite difficult. An indirect evaluation is possible using the hospital registrations for DM complications, recorded by the National School of Management and Public Health, with some certain limitations. The records are referring to the hospitals indicators using the classification for Diagnostic Related Group (DRG), the United States version HCFA DRG v. 18. The limitations of the study are referring to some aspects: these counts may include multiple hospitalizations by the same individuals, which are usually for patients with diabetes; the unavailability of data for hospitalization costs; we cannot separate the cases between type 1 and type 2 diabetes or by age-groups (4). RESULTS Despite the facilities assured through the national health program, the burden of DM over the health system is quite heavy due to the large number of patients having complications. The hospitals are facing with problems of acute episodes of DM, which is a chronically condition. According to the database of The National School of Public Health and Management, the number of diabetic cases with severe complications and co-morbidities (CC) is increasing 484

3 An indirect evaluation of the national program of diabetes mellitus study case of Romania between 2010 and The cases without severe CC are slightly decreasing during The total amount of days in hospitals is more than one million between and for 185,260 cases (tab. I). TABLE I Number of hospitalized diabetic cases by year, type of complications, and number of days in hospital Year Diagnostic No. of cases Days in hospital Diabetes without severe CC 24, , Diabetes with severe CC 23, ,571 Diabetes without severe CC 21, ,383 Diabetic foot 1,919 21, Diabetes with severe CC 24, ,390 Diabetes without severe CC 19, ,675 Diabetic foot 1,878 21, Diabetes with severe CC 26, ,229 Diabetes without severe CC 15,522 95,082 Diabetic foot 2,142 23, first trim. Diabetes with severe CC 7,178 47,648 Diabetes without severe CC 4,353 25,719 Total 1,143,816 TABLE II Number of hospitalized diabetic cases by year, and type of care Year Diagnostic No. of cases in No. of cases in acute care units chronic care units Diabetes without severe CC 23, Diabetes with severe CC 22, Diabetes without severe CC 20, Diabetic foot 1, Diabetes with severe CC 23, Diabetes without severe CC 19, Diabetic foot 1, Diabetes with severe CC 25, Diabetes without severe CC 14, Diabetic foot 2, first trim. Diabetes with severe CC 23, Diabetes without severe CC

4 Maria Liliana Iliescu, Dana Teodora Anton The inpatients with complications were hospitalized in acute care units or chronic care units. It is evident that patients, or more correctly, the number of cases receiving health care for DM acute episodes are far greater than those receiving health care in chronic units: in average, 32 acute episodes to 1 in chronic care units (tab. II). The average length of stay (ALOS) is varying due to complications and type of received care (acute or chronic) (tab. III). TABLE III. Average length of stay for diabetic cases by year, and type of care Year Acute care Chronic care Diagnostic ALOS (days) ALOS (days) Diabetes without severe CC Diabetes with severe CC Diabetes without severe CC Diabetic foot Diabetes with severe CC Diabetes without severe CC Diabetic foot Diabetes with severe CC Diabetes without severe CC Diabetic foot first trim. Diabetes with severe CC Diabetes without severe CC 0 0 DISCUSSION Despite the facilities offered by the national health program, the hospital burden due to DM is large. In Romania, funds allocated in 2010 to the National Program for Diabetes and other Metabolic Diseases amount to approximately EUR 57,731,000, representing 1.47% of total health expenditure (5). The amount of money is directly increasing with the age of the diabetic patient, because the duration of diabetes is the main factor determining complications prevalence, the most important factor associated with an increased risk of complications being the glycemic control (5, 6). The ALOS is higher than other values registered in other countries. For example, in US, in 2004, the mean length of stay for hospitalizations among patients with diabetes was 5.5 days, which was one day longer compared to non-diabetes stays (7). According to Centers for Disease Control and Prevention, the value for ALOS of hospital discharge with diabetes as first-listed diagnosis decreased from 8.2 days in 1988 to 5.0 days in 2009 (8). In Singapore, admission for diabetes with complications varies within the limits 4.9 to 10.1 days (9). This study reveals some of the indirect outcomes of the national program for diabetes, these indicators having more possible explanations. The level of socioeconomic development of Romania could be one of them. The treatment for the DM 486

5 An indirect evaluation of the national program of diabetes mellitus study case of Romania is not only a medical one. It implies, as a first step, a changing in life style, a dietary regimen. These changes require special attention, considerable expenses, and psychological efforts from patients and their families. The lack of money could be, for many patients, an obstacle to keep the blood sugar under control, so most of them are not able to have a proper diet. On the other hand, many diabetic patients consider that the medical doctor specialist in diabetes is the only in charge with their health condition. Or it is known that DM, as the other chronic diseases, requires ongoing adjustments by the affected person and interactions with the health care system (10). So we want to underline the importance of family doctor, who is not, unfortunately, part of this equation in many cases. His role is to help patients to achieve the self-management of the diabetes. CONCLUSIONS Even all people have access to periodic checkups for diabetes carried out by specialists, and injectable insulin and pens, insulin pumps and accessories, blood glucose monitoring strips and meters, lipid testing, retinopathy screening are fully reimbursed, the indirect evaluation of the National health program for DM indicated some deficiencies not at the central level, but at the local one. There is a lack of care coordination between specialist in hospital / ambulatory units and family doctors, the last ones being the most indicated to follow-up continuously the diabetic patients. As a consequence, patients are inadequately trained to manage their illnesses in the specific socio-economic conditions of their life. REFERENCES 1. International Diabetes Federation. Diabetes Atlas, fifth edition, Brussels, International Diabetes Federation, *** 3. *** MonitorulOficial 893 din 30 decembrie 2010 (M. Of. 893/2010). 4. *** 5. International Diabetes Federation. The Policy Puzzle s Europe Making Progress?, Brussels, International Diabetes Federation, Cobuz M, Cobuz C. Chronic complications of type 1 diabetesmellitus in children. Rom J Diabetes NutrMetab Dis. 2012; 19(3): Russo C.A, Jiang M.P.H., Jiang H.J. Statistical Brief #17: Hospital Stays among Patients with Diabetes, CDC, Centers for Disease Control and Prevention. National Center for Chronic Disease Prevention and Health Promotion, Bucharest. 9. Division of Diabetes Translation available onlinehttp:// fig2.htm. 10. Ministry of Health, Singapore. Admission for diabetes with complications, moh_web/ home/costs_and_financing. 11. ***Improving Chronic Illness Care.Johns Hopkins University, Baltimore, supported by The Robert Wood Johnson Foundation, 487