Aspectos metodológicos de los procesos asistenciales integrados (PAI) / Methodological aspects of integrated care pathways

Un proceso asistencial integrado (PAI) es una herramienta cuyo propósito es aumentar la efectividad de las actuaciones clínicas a través de una mayor coordinación y garantía de continuidad asistencial. Los PAI sitúan al paciente como el eje central de la organización asistencial. Se definen como el conjunto de actividades que realizan los proveedores de la atención sanitaria con la finalidad de incrementar el nivel de salud y el grado de satisfacción de la población que recibe los servicios. La elaboración de un PAI precisa analizar el flujo de actividades, la interrelación entre profesionales y dispositivos asistenciales y las expectativas del paciente. En este artículo se presenta y se discute la metodología para la elaboración de un PAI, así como los factores de éxito para su definición y su efectiva implantación. Se explica también, a modo de ejemplo, el reciente PAI para hipoglucemias en personas con diabetes mellitus tipo 2 elaborado por un equipo multidisciplinar y avalado por varias sociedades científicas (AU)

An Integrated Healthcare Pathway (PAI) is a tool which has as its aim to increase the effectiveness of clinical performance through greater coordination and to ensure continuity of care. PAI places the patient as the central focus of the organisation of health services. It is defined as the set of activities carried out by the health care providers in order to increase the level of health and satisfaction of the population receiving services. The development of a PAI requires the analysis of the flow of activities, the inter-relationships between professionals and care teams, and patient expectations. The methodology for the development of a PAI is presented and discussed in this article, as well as the success factors for its definition and its effective implementation. It also explains, as an example, the recent PAI for Hypoglycaemia in patients with Type 2 Diabetes Mellitus developed by a multidisciplinary team and supported by several scientific societies (AU)

[Methodological aspects of integrated care pathways]. / Aspectos metodológicos de los procesos asistenciales integrados (PAI).

An Integrated Healthcare Pathway (PAI) is a tool which has as its aim to increase the effectiveness of clinical performance through greater coordination and to ensure continuity of care. PAI places the patient as the central focus of the organisation of health services. It is defined as the set of activities carried out by the health care providers in order to increase the level of health and satisfaction of the population receiving services. The development of a PAI requires the analysis of the flow of activities, the inter-relationships between professionals and care teams, and patient expectations. The methodology for the development of a PAI is presented and discussed in this article, as well as the success factors for its definition and its effective implementation. It also explains, as an example, the recent PAI for Hypoglycaemia in patients with Type 2 Diabetes Mellitus developed by a multidisciplinary team and supported by several scientific societies.

Análisis del proceso asistencial de los pacientes con diabetes mellitus tipo 2 y comorbilidad asociada atendidos en el Sistema Nacional de Salud en España: una perspectiva de los profesionales médicos. Estudio IMAGINE / Analysis of the healthcare process of patients with type 2 diabetes mellitus and associated comorbidity treated in Spain's National Health System: A perspective of medical professionals. IMAGINE study

Objetivos. Analizar la atención que reciben los pacientes con diabetes mellitus tipo 2 (DM2) y comorbilidad en el Sistema Nacional de Salud español. Pacientes y métodos. Estudio transversal mediante encuesta online. Participaron 302 médicos de familia, internistas y endocrinólogos, reclutados por sus respectivas sociedades científicas, de manera voluntaria y no retribuida. Resultados. Los pacientes con DM2 y comorbilidad son atendidos mayoritariamente en Atención Primaria (71,8%). Un 40% son derivados a atención hospitalaria, principalmente por insuficiencia renal, mal control glucémico y evaluación de retinopatía. Solo el 52% de los encuestados realizaban conciliación farmacológica en la transición entre niveles asistenciales. El 58% manifestaron realizar interconsultas, sesiones clínicas o consultorías entre niveles asistenciales. Los 3 principales factores identificados para mejorar el seguimiento y control de la DM2 con comorbilidad fueron el trabajo multidisciplinar (80,8%), la formación continuada de los profesionales sanitarios (72,3%) y los programas de educación terapéutica (72%). La falta de tiempo, la carencia de personal cualificado en intervenciones sobre el estilo de vida y las deficiencias organizativas fueron citadas como las principales barreras para la mejora asistencial en estos pacientes. Conclusiones. La mayoría de los pacientes con DM2 y comorbilidad son atendidos en Atención Primaria. Promover la atención multidisciplinaria y los programas formativos para profesionales y pacientes puede contribuir a mejorar la calidad asistencial. La conciliación terapéutica representa un área prioritaria de mejora en esta población (AU)

Objectives. To analyse the care received by patients with type 2 diabetes mellitus (DM2) and comorbidity in Spain's National Health System. Patients and methods. Cross-sectional study using an online survey. A total of 302 family physicians, internists and endocrinologists participated in the study. The participants were recruited voluntarily by their respective scientific societies and received no remuneration. Results. Patients with DM2 and comorbidity are mostly treated in Primary Care (71.8%). Forty percent are referred to hospital care, mainly due to renal failure, poor glycaemic control and for a retinopathy assessment. Only 52% of those surveyed conducted medication reconciliation in the transition between healthcare levels. Fifty-eight percent reported conducting interconsultations, clinical meetings or consultancies between healthcare levels. The 3 main factors identified for improving the follow-up and control of DM2 with comorbidity were the multidisciplinary study (80.8%), the continuing education of health professionals (72.3%) and therapeutic education programmes (72%). A lack of time, a lack of qualified personnel for lifestyle interventions and organisational shortcomings were mentioned as the main obstacles for improving the care of these patients. Conclusions. Most patients with DM2 and comorbidity are treated in Primary Care. Promoting multidisciplinary care and training programmes for practitioners and patients can help improve the quality of care. Therapy reconciliation represents a priority area for improvement in this population (AU)

Analysis of the healthcare process of patients with type 2 diabetes mellitus and associated comorbidity treated in Spain's National Health System: A perspective of medical professionals. IMAGINE study.

OBJECTIVES: To analyse the care received by patients with type 2 diabetes mellitus (DM2) and comorbidity in Spain's National Health System. PATIENTS AND METHODS: Cross-sectional study using an online survey. A total of 302 family physicians, internists and endocrinologists participated in the study. The participants were recruited voluntarily by their respective scientific societies and received no remuneration. RESULTS: Patients with DM2 and comorbidity are mostly treated in Primary Care (71.8%). Forty percent are referred to hospital care, mainly due to renal failure, poor glycaemic control and for a retinopathy assessment. Only 52% of those surveyed conducted medication reconciliation in the transition between healthcare levels. Fifty-eight percent reported conducting interconsultations, clinical meetings or consultancies between healthcare levels. The 3 main factors identified for improving the follow-up and control of DM2 with comorbidity were the multidisciplinary study (80.8%), the continuing education of health professionals (72.3%) and therapeutic education programmes (72%). A lack of time, a lack of qualified personnel for lifestyle interventions and organisational shortcomings were mentioned as the main obstacles for improving the care of these patients. CONCLUSIONS: Most patients with DM2 and comorbidity are treated in Primary Care. Promoting multidisciplinary care and training programmes for practitioners and patients can help improve the quality of care. Therapy reconciliation represents a priority area for improvement in this population.

Hacia un manejo integral del paciente con diabetes y obesidad. Posicionamiento de la SEMI, SED, redGDPS, SEC, SEEDO, SEEN, SEMERGEN y SEMFYC / Position statement of the SEMI, SED, redGDPS, SEC, SEEDO, SEEN, SEMERGEN y SEMFYC

La obesidad y el sobrepeso constituyen la principal causa modificable de diabetes tipo 2 (DM2). En el momento del diagnóstico de la diabetes tipo 2 se debe establecer el grado de obesidad según el índice de masa corporal y, en los pacientes con sobrepeso, determinar el perímetro de la cintura. El adecuado tratamiento de la DM2 requiere un abordaje simultáneo del sobrepeso/obesidad y el resto de factores de riesgo cardiovascular, como la hipertensión, la dislipemia o el tabaquismo. Las intervenciones no farmacológicas (dieta, ejercicio) con beneficio demostrado en la prevención y tratamiento del paciente con DM2 y sobrepeso/obesidad deben seguir un enfoque individualizado y multidisciplinario, con programas estructurados dotados de recursos específicos. La ganancia de peso asociada al tratamiento antidiabético puede dificultar el control glucémico, comprometer la adherencia al tratamiento, empeorar el perfil de riesgo vascular de los pacientes y limitar los beneficios cardiovasculares del tratamiento. Por ello, es importante evitarla; una medida que resulta coste-efectiva. Los fármacos antidiabéticos con beneficios sobre el peso corporal también han demostrado su beneficio en pacientes con un índice de masa corporal<30kg/m2. Globalmente, el tratamiento del paciente con DM2 y obesidad dependerá tanto del grado de obesidad como de la comorbilidad asociada. Los ensayos clínicos de intervención en DM2 deben contemplar objetivos combinados que incluyan no solo el control glucémico, sino otras variables como el riesgo de hipoglucemia y el efecto del tratamiento sobre el peso corporal (AU)

Obesity and excess weight are the main preventable causes of type 2 diabetes (DM2). When diagnosing type 2 diabetes, clinicians should establish the degree of obesity according to the body mass index (BMI) and, for patients with excess weight, measure the waist circumference. The proper treatment of DM2 requires a simultaneous approach to excess weight/obesity and the other cardiovascular risk factors, such as hypertension, dyslipidaemia and smoking. Nondrug interventions (e.g., diet and exercise) have proven benefits in preventing and treating patients with DM2 and excess weight/obesity and should follow an individual and multidisciplinary approach, with structured programs equipped with specific resources. Weight gain associated with antidiabetic treatment can hinder glycaemic control, compromise treatment adherence, worsen the vascular risk profile and limit the cardiovascular benefits of treatment. Therefore, it is significant to avoid weight gain, a measure that can be cost-effective. Antidiabetic drugs with benefits in body weight have also demonstrated their benefit in patients with BMIs <30. In general, the treatment of patients with DM2 and obesity will depend both on the degree of obesity and the associated comorbidity. Clinical trials on DM2 intervention should consider combined objectives that include not only glycaemic control but also other variables such as the risk of hypoglycaemia and the effect of treatment on body weight (AU)

Position statement of the SEMI, SED, redGDPS, SEC, SEEDO, SEEN, SEMERGEN y SEMFYC.

Obesity and excess weight are the main preventable causes of type 2 diabetes (DM2). When diagnosing type 2 diabetes, clinicians should establish the degree of obesity according to the body mass index (BMI) and, for patients with excess weight, measure the waist circumference. The proper treatment of DM2 requires a simultaneous approach to excess weight/obesity and the other cardiovascular risk factors, such as hypertension, dyslipidaemia and smoking. Nondrug interventions (e.g., diet and exercise) have proven benefits in preventing and treating patients with DM2 and excess weight/obesity and should follow an individual and multidisciplinary approach, with structured programs equipped with specific resources. Weight gain associated with antidiabetic treatment can hinder glycaemic control, compromise treatment adherence, worsen the vascular risk profile and limit the cardiovascular benefits of treatment. Therefore, it is significant to avoid weight gain, a measure that can be cost-effective. Antidiabetic drugs with benefits in body weight have also demonstrated their benefit in patients with BMIs <30. In general, the treatment of patients with DM2 and obesity will depend both on the degree of obesity and the associated comorbidity. Clinical trials on DM2 intervention should consider combined objectives that include not only glycaemic control but also other variables such as the risk of hypoglycaemia and the effect of treatment on body weight.

Barriers associated with poor control in Spanish diabetic patients. A consensus study.

BACKGROUND: Delphi technique allows developing a multidisciplinary consensus to establish solutions. AIM: To identify barriers and solutions to improve control in patients with Type-2 Diabetes Mellitus (DM2). METHODS: An observational study using the 2-round Delphi technique (June-August 2011). A panel of 108 experts in DM2 from medical and nursing fields (primary care providers and specialists) from different regions completed via email a questionnaire with 41 Likert statements and 9 scores for each one. Level of agreement was assessed using measures of central tendency and dispersion. We analysed commonalities/differences between the two groups (Kappa index and McNemar chi-square). RESULTS: Response rate: 65%. Degree of agreement: 63.4% (95% CI 48.7-78.1%) in medicine, and 78.1% (95% CI 65.4-90.8) in nursing (p > 0.05). Overall level of agreement: Kappa = 0.43, (χ(2) = 2.5 p > 0.05). Regarding non-compliance with therapy, it improves with: the information to the partner/family/caregiver, patient education degree in diabetes, patient motivation and ability to share and agree on decisions with the patient. Clinical inertia improves with: motivation degree of healthcare professionals and the calculation of cardiovascular risk; and gets worse with: the shortage of time in consultation, absence of data in medical record, border high limits measurements accepted as normal readings, lack of a treatment goals, lack of teamwork (Physician/Nurse), scarcity of resources and lack of alarm systems in the electronic medical record on goals to achieve. CONCLUSION: The participants achieved an agreement in interventions in non-therapeutic compliance and clinical inertia to improve DM2 control.

Recomendaciones para el tratamiento farmacológico de la hiperglucemia en la diabetes tipo 2 / No disponible

No disponible

Recomendaciones para el tratamiento farmacológicode la hiperglucemia en la diabetes tipo 2. Documento de consenso / No disponible

No disponible

Síndrome metabólico / No disponible

La obesidad infantil es el principal factor de riesgo de obesidad en el adulto, así como de síndrome metabólico, diabetes mellitus tipo 2 y del desarrollo de enfermedades cardiovasculares, que reducen la calidad y duración de la vida. El síndrome metabólico es un diagnóstico clínico que identifica una población con elevado riesgo cardiovascular. La resistencia a la insulina parece ser el vínculo común y el factor promotor de la cascada de disturbios metabólicos, modulados por factores genéticos y ambientales. El síndrome metabólico puede demostrarse en la edad pediátrica, pero actualmente no existen criterios claramente definidos. Los criterios de la International Diabetes Federation (IDF) para niños y adolescentes son los más utilizados, por su fácil manejo; la medida de la cintura es el principal componente. Se necesita una definición internacional para poder comparar los resultados de los diferentes estudios, y, hasta que no ocurra, no se debe diagnosticar por debajo de los 10 años(AU)

Children’s obesity is the main risk factor for adult obesity, as well as for the metabolic syndrome, type 2 diabetes mellitus and cardiovascular diseases, which reduce life quality and expectancy. The metabolic syndrome is a clinical diagnosis that identifies a population that has high risk of cardiovascular diseases. Insulin resistance appears as the common link and the trigger factor of metabolic impairments, modulated by genetic and environmental circumstances. The metabolic syndrome can be found in children, but at present it isn’t clearly defined. The International Diabetes Federation’s (IDF) criteria for children and adolescents are used the most because of their easy management; waist measurement is its principal component. An international definition is needed to be able to compare different studies, and until this isn’t accomplished, it shouldn’t be diagnosed in children less than 10 years(AU)

Prevención de la diabetes tipo 2 basada en la terapianutricional y/o el aumento de la actividad física / Prevention of type 2 diabetes based on nutritional therapy

El aumento de la incidencia de diabetes tipo 2 está asociado al estilode vida occidental. Los programas de intervención dirigidos aaumentar el ejercicio, combinados con una alimentación adecuada,son capaces de retrasar el desarrollo de este tipo de diabetes ensujetos de riesgo. Los resultados son incluso mejores que con elabordaje farmacológico. La prevención de la diabetes mediante laintervención sobre la modificación del estilo de vida es coste-efectivadesde la perspectiva de un sistema público de salud. Es importanteidentificar a los individuos con alto riesgo de desarrollar diabetespara prevenir el progreso de la hiperglucemia. No hay datossuficientes sobre la prevención de la diabetes sólo con ejercicio, nisobre el efecto en la morbimortalidad. Parece necesario realizar estudiosque analicen los beneficios del ejercicio, solo o combinadocon la dieta, en la morbilidad y mortalidad cardiovascular (AU)

The increasing incidence of type 2 diabetes is associated with thewestern lifestyle. Intervention programs oriented to increasing exercisecombined with an adequate nutrition therapy have a protectiveeffect against the development of type 2 diabetes in people at risk.These results are even better than with the pharmacologic approach.Prevention of diabetes with lifestyle intervention is cost-effectivefrom a health care point of view. It is important to detect people athigh risk to develop type 2 diabetes to prevent progression of hyperglycemia.There are not enough data with exercise alone neither ondiabetes prevention nor in morbidity and mortality. There is a needfor studies exploring the effect of interventions with exercise alone orcombined with nutrition therapy on cardiovascular morbidity andmortality (AU)

Reducción del colesterol LDL por debajo de los 100 mg/dL: ¿un objetivo alcanzable desde atención primaria? / LDL-Cholesterol reduction below 100 mg/dL. An achievable target in Primary Care?

No disponible

Estrategias de tratamiento combinado con secretagogos / Strategies for combined treatment with secretagues

La diabetes tipo 2 es un trastorno metabólico caracterizado por dos alteraciones fundamentales: el déficit de secreción de insulina pancreática y la resistencia a la acción periférica de la insulina. Los beneficios del control intensivo de la glucemia para reducir las complicaciones de la DM2 han sido demostrados en estudios de intervención a largo plazo. La incapacidad para alcanzar los adecuados controles glucémicos al inicio del curso evolutivo de la diabetes puede resultar por el clásico abordaje conservador escalonado con monoterapia trás fracaso de la dieta y el ejercicio, seguido de terapia oral combinada y posterior insulinización. Un tratamiento alternativo, podría ser la combinación precoz de los diferentes fármacos orales aprovechando sus beneficios aditivos sobre el control glucémico, no así los efectos secundarios. Las mejores asociaciones son aquellas que utilizan fármacos con diferente mecanismo de acción: sulfonilureas y metformina o tiazolidindionas, glinidas y metformina o tiazolidindionas, y cualquiera de ellos con acarbosa. Los datos actuales permiten recomendar la adición de un tercer fármaco oral si el control es insuficiente. La aproximación terapéutica inicial al tratamiento de la DM2 está protocolizada en los estadios iniciales de la enfermedad, mientras que la individualización resulta imprescindible con la evolución de la diabetes

Type 2 diabetes is a metabolic disorder characterized by two major defects: decreased insulin secretion by the pancreas and resistance to the action of insulin in the peripheral tissues. The benefits of intensive glycemic control in reducing microvascular complications of type 2 diabetes have been clearly demonstrated in long-term interventional trials. The inability to achieve adequate glycemic control early in the course of diabetes may result in part from the typical conservative stepwise treatment approach that include monotherapy initiated after failure with diet and exercise, followed by a combination of oral antiglycemic agents, and ultimately insulin therapy. An altemative approach, may be the early use of combination agents avoiding long delays between steps using the additive effects of different classes of agents, although their side effects usually are not. The best combination therapy should be the use of drugs with different mechanisms of action: Sulfonylurea and metformin or thiazolidinediones, meglitinides and metformin or thiazolidinediones, and any of the drugs plus acarbose. Available data suggest adding a third oral agent is also appropriate. A standardized approach to the pharmacologic therapy for type 2 diabetes is appropriate for early treatment steps of the disease whereas increasing individualization becomes necessary as the duration of the disease increases

Optimización del tratamiento de la diabetes tipo 2: ajustar el tratamiento al paciente y a la enfermedad / Optimising treatment of type-2 diabetes: adjusting the treatment to both patient and illness

No disponible