Cuban Medical Research

Quality of Life
for Diabetic Patients

Alberto Quirantes Hernández, MD.¹
Leonel López Granja, MD. 2
Vladimir Curbelo Serrano, MD. 3
José A. Montano Luna, MD. 3
Pedro Machado Leyva, MD. 3
lberto Quirantes Moreno, MD. 4

ABSTRACT: All diabetic patients served by the Cerro Teaching Polyclinic in Cerro municipality, Havana, were studied. This municipality has a population of 35,157 inhabitants. The incidence of diabetes was found to be 39.5 per 1,000 inhabitants. The characteristics, complications, mortality and lifestyle of these patients were analyzed. In this article, we propose implementation of a program called "Improving the Quality of Life for Diabetic Patients", and offer a description of its structure and dynamics. The structure of this program is based on the interrelation between primary and secondary levels of attention, the latter including clinical and surgical, pediatric, and obstetrics and gynecological hospitals. The dynamics of our program is based on what we have called "The Seven Rules of Success for Diabetic Patients". The purpose of our program is to reduce mortality, complications and expenses (by 10% per year) related to
this disease.

Subject headings: QUALITY OF LIFE; DIABETES MELLITUS;
PROGRAM DEVELOPMENT; LIFESTYLE; PHYSICIANS, FAMILY;
PRIMARY HEALTH CARE.

Diabetes mellitus is a health problem that affects between 2% and 5% of the world's population. The Declaration of the Americas on Diabetes states that when this disorder is inefficiently controlled, it can give rise to significant economic burdens both for patients and for society, and that, depending on the country, diabetes can represent between 5% and 14% of healthcare expenses. The Declaration adds, however, that it is possible to promote health and prevent complications in diabetic patients through the proper control of glycemia and through the modification of cardiovascular risk factors. 1

Our study presents data on the prevalence of this disorder and the characteristics of all patients served by the Cerro Teaching Polyclinic which, given the importance of this institution, can be considered representative of the trends in the entire municipality. We also present the structure of our program "Improving the Quality of Life for Diabetic Patients" and the expected reduction in expenses resulting from its implementation. Besides the reduction in expenses, the aim of this program, now being implemented, is to reduce mortality and complications from diabetes mellitus in Havana's Cerro municipality.

Methods

Data was obtained on the population in Cerro municipality and diabetic patients diagnosed in this territory by the end of 1996 from the Statistics Office of the Municipal Division of Health, as well as from the 60 neighborhood family doctors' offices within the community served by the Cerro Teaching Polyclinic. This data was considered representative of the situation in this municipality.

Cerro municipality has a population of 35,157 inhabitants. Of these, 1,390 are diabetic (542 men and 848 women), which constitutes an overall rate of 39.5 per 1,000 inhabitants (33.4 per 1,000 inhabitants for men; 44.8 per 1,000 inhabitants for women).

The population served by this polyclinic was divided into four age groups: 0-19, 20-39, 40-59 and 60 years and over. We called these groups "bio-functional age groups" (BFAG). The rates of prevalence of diabetes by group were: 1.3, 14.2, 53.4, 118.3.

The prevalence of diabetes in both sexes by bio-functional age group was similar to the overall prevalence rate found for each age group. As to the type of diabetes, there were 154 patients (11.1%) with Type I diabetes and 1,236 (88.9%) with Type II diabetes. The prevalence of each type of diabetes by bio-functional age group was: Type I: 81.8%, 25.0%, 9.5% and 7.9%; Type II: 18.2%, 75.0%, 90.5% and 92.1%.

Several health problems related to diabetes mellitus were studied in these diabetic patients: arterial hypertension, ischemic cardiopathy, cardiac infarction, cerebrovascular disorders, diabetic foot ulcers, amputations, secondary blindness due to diabetes, chronic renal failure and overweight. We also investigated the number of diabetics who had been hospitalized or who had died due to diabetes during 1996 (the year under study).

Various lifestyle parameters of the diabetic population were quantified following uniform criteria for all 60 family doctors' offices where we carried out our survey. They included: patients who systematically kept appointments at the doctor's office for check up and evaluation, patients who systematically kept appointments with chiropodists and dental services, patients with no education concerning their condition, patients with a sedentary lifestyle and habitual smokers.

With these parameters, we present and discuss our program "Improving the Quality of Life for Diabetic Patients", whose aim is to reduce mortality, complications and expenses due to diabetes mellitus in a manner that is simple, effective, economical and verifiable.Based on the overall budget of the Cuban Ministry of Public Health for the country, for the City of Havana and for the Dr. Salvador Allende Hospital, and calculating the expenses due to diabetes mellitus at these three levels, we predict a probable reduction in these expenses by 10% per year during the first three years the program is implemented.

Results

Table 1 shows the health problems associated with diabetes mellitus that we found in the diabetic population studied, the number of patients hospitalized and the number of them who died due to this disorder. The most prevalent health problem was arterial hypertension (35.2%), followed by overweight 31.1%), ischemic cardiopathy (19.4%), cardiac infarction (4.3%), cerebrovascular accidents (3.2%), diabetic foot ulcers (3.2%), amputations (2.1%), blindness (1.6%) and secondary chronic renal failure (1.5%). Diabetic patients who were hospitalized (4.1%) and those who died (3.2%) during the year studied were included in our study when diabetes was the direct or fundamental cause of hospitalization or death.

Table 1. Morbidity and Mortality in Diabetic Patients, Cerro Polyclinic.

Table 2 shows that the high incidence of unkept doctors' appointments for diabetic patients, the lack of education concerning their disorder, the habit of smoking and a predominantly sedentary lifestyle among a considerable number of these patients are indicative of a low perception on the part of patients and their relatives of the risks involved in these behaviors, mainly due to lack of information and follow-up.

Table 2. Lifestyle of Diabetic Patients, Cerro Polyclinic.

The Cuban Ministry of Public Health's budget for the entire country is 1,187,166,400 Cuban pesos; 153,025,000 pesos for the City of Havana; 8,656,500 pesos for the Dr. Salvador Allende Teaching Hospital. Expenses due to diabetes mellitus at each level are: 118,716,640 (10% of the national health budget), 15,302,500 (10% of the budget for the City of Havana), and 913,395 (10.5% of the budget for the Dr. Salvador Allende hospital), respectively.

Discussion

We decided to divide age groups into four categories or "bio-functional age groups" (BFAG) due to the fact that each age group noticeably reflects a stage in the course of life: 0-19 (physical, psychological and educational development group), 20-39 (group whose projection in life focuses on work, education and family), 40-59 (maximum work and intellectual performance, period of maturation regarding the family and social environment), 60 years and over (group in which life begins to decline, people retire, chronic disorders are more frequent, and there is a greater tendency to suffer from depression).

Our findings show that the characteristics of diabetes in the patients studied do not differ greatly from what is typically reported in the medical literature: a higher prevalence of this disorder in women than in men and among people over 40, as well as a predominance of Type II over Type I diabetes. The overall rate in this municipality is 39.5 per 1,000 inhabitants.

The complications found in our study, the number of hospitalizations and the number of deaths (in a certainly important proportion), reflect the lifestyle of this diabetic population. Unquestionably, an inadequate lifestyle leads to a poor metabolic control, which is known to be an important risk factor for the onset of complications in diabetic patients. 2,3 Furthermore, almost one third of the patients studied were overweight, which is an important element in the development of complications. 4-6

One fourth of the patients studied were smokers, a very harmful habit that has been shown to cause several health problems, including the progression of vascular disorders and chronic renal failure. 7

Macroangiopathic complications of the nervous and cardiovascular systems and of the lower limbs are strongly associated with the poor control of diabetic patients. 8-10 We can affirm that such lack of control is a direct consequence of the deficient or nonexistent diabetological education of diabetic patients and their relatives, which results in a low perception of risk and in the nonobservance of elemental preventive measures. Table 2 shows deficient utilization of the health services offered to the entire population, and which play an essential role in the prevention of many, and sometimes very dangerous, complications in diabetic patients.

Based on our findings, we can clearly recognize that there is still much to do to change inadequate lifestyles in the diabetic population that would improve the quality of their lives. We are aware of the urgent need to promote changes in the lifestyles of many diabetic patients and for the need to identify those habits that need changing. What we do not seem to be fully aware of in our programs is how to do that.

Due to the above-mentioned considerations, we decided to design a program whose fficient application would be based on four essential criteria:

- that it be highly effective for the great majority of diabetic patients.
- that results be objectively verifiable.
- that it be an exceptionally economical program.
- that it be clear and easy to implement for any doctor or nurse, principally for
   those working in primary healthcare.

Accordingly, such a program should be led by groups in each municipality, composed of professionals from the primary-care level (family doctors' offices), and secondary-are level (clinical and surgical, pediatric and obstetrics and gynecological hospitals). These joint municipal leadership groups would constitute an example of the interrelation between the primary and secondary healthcare levels, and they would respond to similar structures set up on a provincial and national level. We should take advantage of the fact that the primary and secondary levels have greater knowledge and experience in the handling of diabetic patients. These are the levels that treat the immense majority of diabetics in the country: the primary level for ambulatory patients, including patient education; and the secondary level for diabetics hospitalized for acute or chronic complications. Moreover, both levels contain practically all the specialties that a diabetic might require for his or her care and control. Another advantage lies in the existence of these two levels in all parts of the country.

The family doctor's office, at the primary-care level, should be considered Center for Diabetic Attention and Education, since it includes basic team for diabetic attention--the family physician and nurse. Undoubtedly, such centers can play a crucial role in the
care of diabetic patients, as well as in the education of patients and family members. This model permits continuity in treatment by the same health team, which diabetics prefer. (11-13) The secondary care level would offer primary care physicians continuing education courses in diabetes mellitus, including a detailed explanation of how to apply the program in each family doctor's office. Its other function would consist of carrying out periodic controls to ensure the correct application of the program, adopting the necessary measures towards this end.

The dynamics of the program consist in concentrating concepts that at times are disperse within different specialties, and oftentimes not systematically applied to every diabetic patient. We have done this by summarizing the concepts in "Seven Rules for Success for the Diabetic Patient". We also decided to award patients who consistently follow all seven rules, by naming them "Seven Stars Diabetics", hoping their example will encourage other diabetics.

Consistent adherence to the rules would be reviewed once a month by the neighborhood doctor-and-nurse team, in group sessions we have called "Diabetes Education Plenaries", which we would also envision as support groups for diabetics and their families. In this way, and by using the influence of the doctor and nurse, diabetic patients would be encouraged to adopt new lifestyles that would have a positive impact on their health and well-being. These suggestive methods would include repetition encouraging patients' desire to reach the quality of life attained by patients following the rules.

The "Seven Rules for Success for the Diabetic Patient¨" are:

1) Attend the monthly Diabetes Education Plenaries.
2) Visit the family doctor as scheduled, on a quarterly basis.
3) Visit the chiropodist on a monthly basis.
4) Visit the dentist every six months.
5) Achieve and/or maintain an ideal weight.
6) Practice systematic physical exercise, as age permits.
7) Do not smoke.

As can be seen, the above-mentioned does not require expensive or sophisticated techniques, nor even full-time dedication, since the activities can be inserted into the daily routine of program participants. All that is needed is an adequate hierarchical structure within the health system, harmonious integration of the primary and secondary healthcare levels, and consistent work with diabetic patients by the community physician-and-nurse team responsible for their health. The central aspect of their work would be carried out during the Diabetes Education Plenaries, since peer group influence will encourage compliance with the remaining 6 rules. The "Seven Rules for Success for the Diabetic Patient" encourages the patient to engage in purely preventive actions, which are accepted worldwide as the most effective means of controlling the disease and preventing complications. (14-18)

The direct and indirect costs of diabetes mellitus are enormous, a fact which has been demonstrated in countries that have studied these costs. (19,20) The time and resources used in this program will allow the country to save considerable sums, as our estimates demonstrate.

With the implementation of our program within a period of 3 years, and obtaining a mere 10% annual reduction in the cost of treating this disease, we can achieve significant savings at whatever level the program is applied-community (hospital), province or the nation. The costs would be reduced by as much as $247,529, $4,146,977 and $47,486,656, respectively. The estimates of these figures are the result of studies on the current cost of diabetes, and of the budget assignments for each of the 3 levels.

Conclusions

Following an analysis of the prevalence, behavior, mortality and consequences of diabetic mellitus complications in an important sector of the population in Cerro municipality, we conclude that the diabetic population's lifestyle can be favorably modified by applying a simple and economic system of prevention at the primary healthcare level with the aid and support of the secondary level. This would bring about a reasonable reduction in mortality, complications and costs resulting from this illness, which we expect would encourage the application of this pilot program in other municipalities across the country.

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This article originally appeared in Spanish in the Revista Cubana de Medicina General Integral, vol. 16, No. 1, pp. 50-6, 2000.

1 Second Degree specialist in Endocrinology.
2 First Degree specialist in Internal Medicine.
3 First Degree specialist in Comprehensive General Medicine.
4 General Practitioner.