The Health Consumer Powerhouse (HCP) is an institution specialized in analyzing and comparing health systems and has carried out several studies on European health systems (www.healthpowerhouse.com).In 2008, HCP made a comparative study on diabetes attention in European countries called European Diabetes Index (EDI) and now, in 2014, the study has repeated.In this note I will comment on the methodology and results of the European Diabetes Index of 2014.
comparing health systems
The study on Diabetes Edi care covers the 28 countries of the European Union and two others that are Norway and Switzerland have been added.The diabetes care assessment scheme consists first of defining how a good diabetes care system should be, and then the functions that a health system should develop to serve patients with diabetes have been described.For each of these functions, indicators that have been measured for each country have been selected.For each indicator, three areas have been defined: good compliance, regular and bad.When there is no data on an indicator, your level is supposed to be bad.Each country receives a score based on compliance with the indicators.The maximum score is 1,000 points, but no country has achieved this score.The country that is closest to the ideal is Sweden with 936 points, while the worst placed is Bulgaria with 473 points.Spain is located in an intermediate score below 633 points in place 18.
Characteristics of a good diabetes care system
Each European country has a different health structure and organization, so the EDI HA study, had to develop an ideal diabetes care system, regardless of how countries are organized.This year has been carried out by an expert advisory committee from several countries, including a Spaniard.It is very interesting to analyze this ideal, because it defines what the objective of diabetes should be.
An ideal health care system should have:
· A transparent health system that shares information about best practices among health services
· A National Diabetes Plan agreed between patients, professionals and health authorities
· Primary care that plays a key role for patient detection
· Qualified professionals as nurses specializing in diabetes and dietitians
· Primary care professionals: doctors, nurses and others, well trained in diabetes care
· Multidisciplinary teams to take care of diabetes and its complications 2/6
· Access to education about diabetes by patients and their relatives
· Reasonable waiting times
· Adhesion to treatment
· Economic access to treatment and health products such as insulin pumps, continuous meters and reactive strips
Periodic controls to detect complications
· A National Registry of Diabetes Cases
The functions and indicators of the health system to attend diabetes well
To achieve the objectives of the previous paragraph, the health system must carry out several activities that are grouped into the traditional functions of the system and then set out:
1. Prevention
2. Diagnosis of patients
3. Service portfolio
4. Access to treatment/care
5. Procedures
6. Results
To measure the proper functioning of the health system, indicators have been selected for each of the functions.In total, 28 indicators have been selected that allow to measure quantified if these functions are done properly.An example of indicatorIt is the percentage of obese patients used to evaluate the prevention function, or the percentage of people with well -controlled glycosylated hemoglobin that is used as an indicator of results.Each indicator has a route that has been divided into three parts, the part with a worst indicator has been summarized with the red color of the traffic light, while the best part receives a green and intermediate a yellow.For example, in the case of the obesity indicator, if a country has a percentage of obese people below 20% it is considered a good result and the country receives the green color, if the percentage of obese people is greater than 22% receives the colorred.Countries with an intermediate situation, that is, with a percentage of obese people between 20 and 22% receive the color yellow.In the case of the hemoglobin control level if the percentage of patients with a hemoglobin level below 7%is more than 60%the country receives a green, while if the percentage is less than 50%, theCountry in question receives a red.The countries located between these two extremes receive the yellow color.
The final assessment
The HCP has compiled the values of the 28 indicators for each country, for this it has used international public sources such as WHO, OECD, etc.He has also used the statistics produced by each country and has finally asked health authorities and experts.This volume of data is a value of this study because it will probably be the most complete and most recent database on the situation of diabetes care in Europe.The International Diabetes Federation has supported this study and many national patients have provided information.3/6 The valuation of the indicators is added in a score for each country and in the end it is a ranking of countries.According to this Sweden ranking, it is the best valued country, followed by Holland, Denmark, the United Kingdom and Switzerland.Spain has a score slightly below the average and is located 18. The public reaction before these rankings usually to be different in the countries that are at the top than in the worst classified countries.The former say it is a great study, while the countries that are below, ignore the study or criticize it openly.In the case of Spain the answer has been to obviate the study.The press picked up the news when the study appeared in Vienna the month of September and the health media did not dedicate more attention.The attention would probably have been different if we were the first of the table, but it was not so.
The value of the study
I think the study is very valuable and provides a treasure of information that should not be missing.The study is valuable because it defines how a good patient care system with diabetes and also for the database on the indicators that has been compiled.In my opinion there is still a very important third value and it can be a tool to improve the quality of attention to
diabetes.The first step to improve the quality of something is to recognize that it is not fully done, I do not say badly, but there are aspects that are improvable.Sometimes we fall into the temptation to say and in the mistake of believing, that our health system is the best in the world and it is not true, and this attitude is very negative because it prevents improving.If on the contrary we adopt an attitude of accepting criticism to analyze the things we can improve, exercise is useful and positive.Suppose we have the attitude to recognize that our way of serving patients with diabetes is not the best in Europe and that we want to improve it.In this case I propose to make the comparative analysis between Sweden, the best country in Europe andSpain, to see what aspects we could improve in.Sweden and Spain in diabetes.
The comparison between the two countries will be done for each health system function in diabetes.
Prevention
In this section six indicators have been used to measure the intensity of efforts to prevent diabetes.The first indicator is the percentage of obese people.Obesity is the clearest risk factor for type 2 diabetes. Sweden has a percentage of obese people below 20% while Spain has more than 22%.Therefore the study values Sweden with a green traffic light and Spain with a red traffic light.The second indicator is physical exercise in schools.Here both Sweden and Spain are below 600h for a 10 -year schooling period, which gives a red traffic light to both countries.The third indicator is the percentage of population that usually uses the bicycle.In Sweden this percentage is exceeding 10%, while in Spain it is less than 5%, therefore green for Sweden and red for Spain.The fourth indicator is the consumption of sugary drinks.Here the 4/6
Two countries are in yellow zone with consumption between 100 and 120 liters per capita and year.The fifth indicator is the consumption of fruits and vegetables and also the two countries are in an intermediate zone between 200 to 250 kg per person and year, and both are yellow.The last indicator is the prevalence of hypertensive.The two countries are below 25% and receive a green.
In summary to assess the prevention of diabetes, six indicators have been used, two on the diet (consumption of vegetables and sugary drinks, the first is positive and the second negative), two about physical exercise (exercise in school and use ofthe bicycle), one about obesity and one about hypertension.Sweden has three green, two yellow and one red, while Spain has a green, two yellow and three red.We have already begun to see things to improve.
Diagnosis
In order to treat a person with diabetes, you have to identify it, that is, you have to make a diagnosis and in diabetes it is not easy, because diabetes symptoms can go unnoticed and sometimes diabetes is discovered when a complication already appears.For this reason there are many people who have diabetes and do not know.The study authors have selected two indicators for this function.The authors recognize that they would have liked to have more indicators, but sometimes there is no information and have had to do without them.The first indicator is whether there is a National Diabetes Registry, that is, a computer place where to identify a person by diagnosis.Sweden has a long tradition in preparing records for various diseases and diabetes exists since 1996 and therefore receives a green.In Spain there is no diabetes record, but there is some regional registry of type 1 and through electronic history you can look for people diagnosis, so the authors of the study are magnanimous and give us a yellow.However, this should encourage us to improve diabetes information systems.The second indicator is whether there is screening for gestational diabetes and here they grant us a green to the two countries.
service portfolio
What services are available for patients with diabetes?A patient with diabetes requires the same services as any patient with a disease: hospitalization, primary care, urgent care, etc., but also requires some specific diabetes services.The authors have selected four specific services: a) Podiatry, b) ophthalmology, c) specific footwear and d) useof metformin.Sweden has every green except the special footwear where a yellow receives, while Spain has green podiatry and ophthalmology, yellow in metformin and red in special footwear.
Access to treatment/care
In this section, the study value the access that the patient with diabetes has to the devices for diabetes care and health education on diabetes.Regarding the devices, three are studied:
5/6 a) Insulin pumps, b) Continuous glucose meter and c) glycemia meter, the latter separates in two indicators one on the strips for type 1 patients and another for type 2. Access to education isVery important for diabetes care because it educates and form the patient to be able to manage the disease.Sweden has the five green indicators, while Spain only has access to reactive strips for type 1 patients.Type 2.
Procedures
This section measure the quality of the periodic care that the patient receives in the form of visits and reviews.In total there are seven indicators, of which five refer to whether the patient is reviewed annually: a) glycosylated hemoglobin, b) feet, c) microalbuminuria and d) cholesterol, and e) E) every two years.The other two indicators measure waiting times for an intervention in view and to obtain education for diabetes.Sweden brings green in all indicators while Spain we have two green: the annual review of cholesterol and waiting time for health education, two yellow that are the annual review of hemoglobin and microalbuminuria, a red one that is the time ofWait for intervention in the view and finally two in which there is no information available, which are: the annual review of the feet and the review every two years of the view.In Spain the protocols say that these things should be done, but the authors have measured not intentions but reality.
Results
The authors have selected four specific results indicators for diabetes: a) Patients who are on dialysis due to diabetes, b) feet amputations, c) % patients with glycosylated hemoglobin of more than 7 % and d) blindness for diabetic reasons.Sweden has green in three and only a yellow on dialysis, while Spain has a green in patients with glycosylated hemoglobin of less than 7%, a yellow in dialysis patients, a red in
feet amputations and has no data on blindness produced by diabetes.In Spain, the excuse is frequently used that inequalities between regions to justify when things are not going well.All European countries have inequalities equal or greater than ours, except when it comes to very small countries.Even Sweden has, as the study acknowledges, differences between the twenties of “counties” that manage health services, and yet they are the best in Europe.Continuing with the positive spirit of this note, we could use the differences to improve.In other words, this comparative exercise could be done at the CCAA level in Spain, not to blame anyone, but to find referents to do better.
Author: Lluis Bohigas Doctor of Economic Sciences and Public Health Master
