Lessons learned in the global fight against diabetes

Diabetes is a growing concern outside of the U.S. The World Health Organization (WHO) recently spotlighted important issues in diabetes on World Diabetes Day on November 14, and will emphasize the importance of diabetes by focusing on diabetes on World Health Day on April 7.

Worldwide there are 38 million deaths per year due to non-communicable diseases. Of these, over 1.5 million are directly attributable to diabetes and many listed under cardiovascular disease may be related to diabetes, according to the WHO. 

In 2014 the global prevalence of diabetes was estimated at 9% for adults over 18 years of age with a much higher prevalence in certain emerging regions. The prevalence of diabetes in the Gulf Cooperative Council nations-Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates- is more than double the rate of all countries in the Organization for Economic Cooperation and Development (including the U.S., Canada and Western Europe), with Saudi Arabia having a rate of nearly 24%.

New approaches hold promise

New care models hold out hope for improving diabetes care in many countries with developed and emerging economies. Primary among these are accountable care arrangements   and the Chronic Care Model (CCM)..

In an article on the Chronic Care Models published in Health Affairs, the authors compare quality of care for patients with type 2 diabetes in a U.S. integrated health system (Geisinger Health System) and a German Sickness Fund (Barmer) with the care of diabetic patients receiving routine care.

The Geisinger Proven Care Diabetes Program incorporates a number of important CCM components such as care directed by a physician and delivered by a team that views the patient and family members as active team members. The team is focused on process and outcome measures of evidence-based care.

In Germany the primary model for CCM is disease management. The Barmer program utilizes general practitioners who enroll patients in the disease management program and organize follow-up care. The program is a structured, primary-care based approach to quality improvement and care coordination.

Patients in both the U.S. and German CCM groups saw increases in the quality of care as measured by increased use of evidence-based interventions (e.g. eye exams), and improvements in the doctor-patient relationship. Patients in the German CCM and in the Geisinger CCM groups had increased satisfaction with medical care. There was a statistically significant increase in quality of life in the German CCM group over the routine care group. This was not seen in the Geisinger patients but both CCM and routine care groups at Geisinger had higher quality of life scores than the German CCM group.

Next: The accountable care approach

Another Health Affairs article on the accountable care approach, describes how this approach can cross key barriers that might prevent high quality care at lower costs. For  example, health insurance payments may be limited to licensed providers thus disadvantaging community-based programs and programs that rely on trained but not licensed personnel. Accountable care approaches can help by engaging the existing provider community in care focused on individual need and chronic conditions. The creation of new types of programs that work in concert with providers and with public health organizations can fill gaps in social and welfare networks.

Successful partnerships in Mexico include Pro Mujer and ClickMedix. Both of these organizations have partnered with the Federal Ministry of Health as well as regional health departments allowing for a successful scale up of activities.

Pro Mujer is a women’s development organization that integrates delivery of multiple services including education, finance and health services. As of December 2014, Pro Mujer had screened 9,751 women in Mexico for diabetes and held 1,340 individualized counseling sessions on nutrition and diabetes management.

ClickMedix, which operates in Mexico, India and the United States, is a mobile connected platform customizing electronic health and diabetes solutions and content for patients.

Both of these organizations have shown improvements in care in Mexico through broad collaborations with the government and providers, but both have financial issues exacerbated by being community based and not being licensed providers. Closer ties to providers and an accountable care funding model in which providers may be willing to pay nonlicensed providers for services can help organizations like this expand both their reach and range of services.

In the U.S., the YMCA diabetes program is very similar. It uses nonlicensed personnel to provide an established intervention for diabetes prevention. The growth of accountable care organizations and other providers with mandates for improving outcomes while taking risk may allow for organizations such as the YMCA to provide services and be paid by the provider to improve the health of the population as well as make more efficient use of scarce resources.

In summary, both developed and developing countries have a challenge in preventing and treating diabetes but also have a lot to gain in reducing mortality, morbidity and healthcare utilization. The trans-border exchange of ideas and programs may result in more efficient community-based programs with wider impact.