Testing a new approach to translate research achievements into improved quality of care worldwide

The aim of the BRIDGES Research net is within the BRIDGES main scope: a) to improve the control and treatment of diabetes in a concerted effort to reduce the development and progression of chronic complications, thus decreasing the cost of its care and improving the quality of life of people with diabetes worldwide, b) to promote the early diagnosis of the disease and prevent its development, and c) to increase the critical mass of translational researchers worldwide. Better access of health providers and authorities to evidence-based practice, replicability and self-sustainability would be the central aim of this new initiative.Fil: Gagliardino, Juan Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); Argentin

Physiological endocrine control of energy homeostasis and postprandial blood glucose levels

The aim of this review is to analyze the different components and the feedback mechanisms involved in the normal control of energy homeostasis and postprandial blood glucose levels. Such control involves exogenous and endogenous factors: while the former include quantity and quality of food intake, the latter involve the balance of glucose intestinal absorption (postprandial period), glucose production and release by the liver and its consumption by peripheral tissues. Adequate secretion and peripheral metabolic effects of insulin play a key role in the control of both processes. Insulin secretion is controlled by the level of circulating substrates and by gastrointestinal hormones. The mechanism for the immediate control of blood glucose levels is modulated by energy homeostasis, with the participation of the above mentioned hormones and others produced at the classical endocrine system and adipose tissue, whose actions integrate at the central nervous system. The alteration of such delicate mechanism of control causes diseases such as diabetes; therefore, identification of the multiple components of this mechanism and comprehension of its normal function would facilitate the selection of effective strategies for diabetes prevention and treatment.Fil: Gagliardino, Juan Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - La Plata. Centro de Endocrinología Experimental y Aplicada. Universidad Nacional de La Plata. Facultad de Ciencias Médicas. Centro de Endocrinología Experimental y Aplicada; Argentin

Possible modulatory effect of endogenous islet catecholamines on insulin secretion

Background: The possible participation of endogenous islet catecholamines (CAs) in the control of insulin secretion was tested. Methods: Glucose-induced insulin secretion was measured in the presence of 3-lodo-L-Tyrosine (MIT), a specific inhibitor of tyrosine-hydroxylase activity, in fresh and precultured islets isolated from normal rats. Incubated islets were also used to measure CAs release in the presence of low and high glucose, and the effect of α 2-(yohimbine [Y] and idazoxan [I]) and α1-adrenergic antagonists (prazosin [P] and terazosin [T]) upon insulin secretion elicited by high glucose. Results: Fresh islets incubated with 16.7 mM glucose released significantly more insulin in the presence of 1 μM MIT (6.66 ± 0.39 vs 5.01 ± 0.43 ng/islet/h, p < 0.02), but did not affect significantly the insulin response to low glucose. A similar enhancing effect of MIT upon insulin secretion was obtained using precultured islets devoid of neural cells, but absolute values were lower than those from fresh islets, suggesting that MIT inhibits islet rather than neural tyrosine hydroxylase. CAs concentration in the incubation media of fresh isolated islets was significantly higher in the presence of 16.7 than 3.3 mM glucose: dopamine 1.67 ± 0.13 vs 0.69 ± 0.13 pg/islet/h, p < 0.001, and noradrenaline 1.25 ± 0.17 vs 0.49 ± 0.04 pg/islet/h, p < 0.02. Y and I enhanced the release of insulin elicited by 16.7 mM glucose while P and T decreased such secretion. Conclusion: Our results suggest that islet-originated CAs directly modulate insulin release in a paracrine manner.Facultad de Ciencias Médica

Relation between cost of drug treatment and body mass index in people with type 2 diabetes in Latin America

Aims Despite the frequent association of obesity with type 2 diabetes (T2D), the effect of the former on the cost of drug treatment of the latest has not been specifically addressed. We studied the association of overweight/obesity on the cost of drug treatment of hyperglycemia, hypertension and dyslipidemia in a population with T2D. Methods This observational study utilized data from the QUALIDIAB database on 3,099 T2D patients seen in Diabetes Centers in Argentina, Chile, Colombia, Peru, and Venezuela. Data were grouped according to body mass index (BMI) as Normal (18.5BMI<25), Overweight (25BMI<30), and Obese (BMI30). Thereafter, we assessed clinical and metabolic data and cost of drug treatment in each category. Statistical analyses included group comparisons for continuous variables (parametric or non-parametric tests), Chi-square tests for differences between proportions, and multivariable regression analysis to assess the association between BMI and monthly cost of drug treatment. Results Although all groups showed comparable degree of glycometabolic control (FBG, HbA1c), we found significant differences in other metabolic control indicators. Total cost of drug treatment of hyperglycemia and associated cardiovascular risk factors (CVRF) increased significantly (p<0.001) with increment of BMI. Hyperglycemia treatment cost showed a significant increase concordant with BMI whereas hypertension and dyslipidemia did not. Despite different values and percentages of increase, this growing cost profile was reproduced in every participating country. BMI significantly and independently affected hyperglycemia treatment cost. Conclusions Our study shows for the first time that BMI significantly increases total expenditure on drugs for T2D and its associated CVRF treatment in Latin America.Fil: Elgart, Jorge Federico. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - la Plata. Centro de Endocrinología Experimental y Aplicada. Universidad Nacional de la Plata. Facultad de Ciencias Médicas. Centro de Endocrinología Experimental y Aplicada; ArgentinaFil: Prestes, Mariana. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - la Plata. Centro de Endocrinología Experimental y Aplicada. Universidad Nacional de la Plata. Facultad de Ciencias Médicas. Centro de Endocrinología Experimental y Aplicada; ArgentinaFil: Gonzalez, Lorena. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - la Plata. Centro de Endocrinología Experimental y Aplicada. Universidad Nacional de la Plata. Facultad de Ciencias Médicas. Centro de Endocrinología Experimental y Aplicada; ArgentinaFil: Rucci, Enzo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - la Plata. Centro de Endocrinología Experimental y Aplicada. Universidad Nacional de la Plata. Facultad de Ciencias Médicas. Centro de Endocrinología Experimental y Aplicada; ArgentinaFil: Gagliardino, Juan Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Científico Tecnológico Conicet - la Plata. Centro de Endocrinología Experimental y Aplicada. Universidad Nacional de la Plata. Facultad de Ciencias Médicas. Centro de Endocrinología Experimental y Aplicada; Argentin

A model educational program for people with type 2 diabetes : A cooperative Latin American implementation study (PEDNID-LA)

Objective - To implement an educational program in 10 Latin American countries and to evaluate its effect on the clinical, biochemical, and therapeutic aspects as well as the economic cost of diabetes. Research design and methods - Educators from each participating country were previously trained to implement the educational model. The patient population included 446 individuals with type 2 diabetes; all patients were <65 years of age, did not require insulin for metabolic control, did not have severe complications of diabetes or life-limiting illnesses, and had not previously participated in diabetes education courses. Clinical and therapeutic data and the cost of their pharmacological treatment were collected 6 months before participation in the educational program (-6 months), on entry into the program (time 0), and at 4, 8, and 12 months after initiation of the program. Results - All parameters measured had improved significantly (P 1c 9.0 ±2.0 vs. 7.8 ± 1.6%; body weight 84.6 ±14.7 vs. 81.2 ±15.2 kg; systolic blood pressure 149.6 ±33.6 vs. 142.9 ± 18.8 mmHg; total cholesterol 6.1 ±1.1 vs. 5.4 ±1.0 mmol/l; and triglycerides 2.7 ± 1.8 vs. 2.1 ±1.2 mmol/l. At 12 months, the decrease in pharmacotherapy required for control of diabetes, hypertension, and hyperlipidemia represented a 62% decrease in the annual cost of treatment ($107,939.99 vs.$41,106.30 [U.S.]). After deducting the additional cost of glucosuria monitoring ($30,604), there was still a 34% annual savings. Conclusions - The beneficial results of this educational model, implemented in 10 Latin American countries, reinforce the value of patient education as an essential part of diabetes care. They also suggest that an educational approach promoting healthy lifestyle habits and patient empowerment is an effective strategy with the potential to decrease the development of complications related to diabetes as well as the socioeconomic costs of the disease.Facultad de Ciencias MédicasCentro de Endocrinología Experimental y Aplicad

Clinical, metabolic and psychological outcomes and treatment costs of a prospective-randomized trial based on different educational strategies to improve diabetes care (PRODIACOR)

Aim To evaluate the effect of system interventions (formalized data collection and 100% coverage of medications and supplies) combined with physician and/or patient education on therapeutic indicators and costs in Type 2 diabetes. Methods Randomized 2x2 design in public health, social security or private prepaid primary care clinics in Corrientes, Argentina. Thirty-six general practitioners and 468 adults with Type 2 diabetes participated. Patients of nine participating physicians were selected randomly and assigned to one of four structured group education programmes (117 patients each): control, physician education, patient education and both, with identical system interventions in all four groups. Outcome measures included glycated haemoglobin, body mass index, blood pressure, fasting glucose, lipid profile, drug consumption, resource use and patient well-being at baseline and every 6 months up to 42 months. Results Glycated haemoglobin decreased significantly from 0.34 to 0.84% by 42 months (P < 0.05); the largest and more consistent decrease was in the groups where patients and physicians were educated. Blood pressure and triglycerides decreased significantly in all groups; the largest changes were recorded in the combined education group. The WHO-5-Lowe score showed significant improvements, without differences among groups. The lowest treatment cost was seen in the combined education group. Conclusions In a primary care setting, educational interventions combined with comprehensive care coverage resulted in long-term improvement in clinical, metabolic and psychological outcomes at the best cost-effectiveness ratio. Trial registration NCT01456806 Keywords Type 2 diabetes management, patient and healthcare provider education, quality of care, patient satisfaction, psychological impactFil: Gagliardino, Juan Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); ArgentinaFil: Lapertosa, Silvia. Ministerio de Salud de la Provincia de Corrientes; ArgentinaFil: Pfirter, Guillermina . Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); ArgentinaFil: Villagra, Mirta. Ministerio de Salud de la Provincia de Corrientes; ArgentinaFil: Caporale, Joaquín E.. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); ArgentinaFil: Gonzalez, Claudio. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); ArgentinaFil: Elgart, Jorge Elgart. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); ArgentinaFil: Gonzalez, Lorena. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); ArgentinaFil: Cernadas, C.. Universidad de Buenos Aires. Facultad de Medicina; ArgentinaFil: Rucci, Enzo. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); ArgentinaFil: Clark, C.. Indiana University; Estados Unido

Possible modulatory effect of endogenous islet catecholamines on insulin secretion

Background: The possible participation of endogenous islet catecholamines (CAs) in the control of insulin secretion was tested. Methods: Glucose-induced insulin secretion was measured in the presence of 3-lodo-L-Tyrosine (MIT), a specific inhibitor of tyrosine-hydroxylase activity, in fresh and precultured islets isolated from normal rats. Incubated islets were also used to measure CAs release in the presence of low and high glucose, and the effect of α 2-(yohimbine [Y] and idazoxan [I]) and α1-adrenergic antagonists (prazosin [P] and terazosin [T]) upon insulin secretion elicited by high glucose. Results: Fresh islets incubated with 16.7 mM glucose released significantly more insulin in the presence of 1 μM MIT (6.66 ± 0.39 vs 5.01 ± 0.43 ng/islet/h, p < 0.02), but did not affect significantly the insulin response to low glucose. A similar enhancing effect of MIT upon insulin secretion was obtained using precultured islets devoid of neural cells, but absolute values were lower than those from fresh islets, suggesting that MIT inhibits islet rather than neural tyrosine hydroxylase. CAs concentration in the incubation media of fresh isolated islets was significantly higher in the presence of 16.7 than 3.3 mM glucose: dopamine 1.67 ± 0.13 vs 0.69 ± 0.13 pg/islet/h, p < 0.001, and noradrenaline 1.25 ± 0.17 vs 0.49 ± 0.04 pg/islet/h, p < 0.02. Y and I enhanced the release of insulin elicited by 16.7 mM glucose while P and T decreased such secretion. Conclusion: Our results suggest that islet-originated CAs directly modulate insulin release in a paracrine manner.Facultad de Ciencias Médica

People with diabetes: adherence to treatment, quality of life and education

La evidencia disponible en la literatura muestra que la calidad de atención de las personas con diabetes, tanto a nivel nacional como internacional, dista mucho de ser la ideal, lo que determina el desarrollo y progresión de las complicaciones crónicas prevenibles de la enfermedad. Esto redunda en un aumento de los costos de su atención y disminución de la calidad de vida de quienes la padecen. Lograr un cambio efectivo de esta situación implica, entre otros objetivos, identificar las causas subyacentes que la determinan. En este sentido en la diabetes y los factores de riesgo asociados, al igual que toda enfermedad crónica, la calidad de atención depende en gran parte de la interacción efectiva entre el médico y el paciente, es decir de un correcto diagnóstico y prescripción apropiada, además de una correcta implementación de la misma.Centro de Endocrinología Experimental y Aplicad

Changes in quality of care and costs induced by implementation of a diabetes program in a social security entity of Argentina

Purpose: To measure the impact of a Diabetes and Cardiovascular Risk Factors Program implemented in a social security institution (OSPERYH) upon short- and long-term clinical/metabolic outcomes and costs of care. Methods: Observational longitudinal cohort analysis of clinical/metabolic data and resource use of 300 adult male and female OSPERYH affiliates with diabetes before (Baseline) and one and three years after implementation of the program. Data were obtained from clinical records (Qualidiab) and the administration´s database. Results: The implementation of the program in "real world" conditions resulted in an immediate and sustainable improvement of the quality of care provided to people with diabetes incorporated therein. We also recorded a more appropriate oral therapy prescription for hyperglycemia and cardiovascular risk factors (CVRF) as well as a decrease of events related to chronic complications. This improvement was associated to an increased use of diagnostic and therapeutic resources, particularly those related to pharmacy prescriptions, not specifically used for the control of hyperglycemia and other CVRF. Conclusion: The implementation of a diabetes program in "real world" conditions results in a significant short- and long-term improvement of the quality of care provided to people with diabetes and other CVRF, but simultaneously increased the use of resources and the cost of diagnostic and therapeutic practices. Since controlled studies have shown improvement in quality of care without increasing its costs, our results suggest the need to include management control strategies in these programs for an appropriate medical and administrative feedback to ensure the simultaneous improvement of clinical outcomes and optimization of the use of resources.Fil: Gagliardino, Juan Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); Argentina. Universidad Nacional de la Plata; ArgentinaFil: Calvo, Héctor. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); Argentina. Universidad Nacional de la Plata; ArgentinaFil: Elgart, Jorge. Universidad Nacional de la Plata; ArgentinaFil: Gonzalez, Lorena. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); Argentina. Universidad Nacional de la Plata; Argentin

Diabetes in Argentina: cost and management of diabetes and its complications and challenges for health policy

Diabetes is an expensive disease in Argentina as well as worldwide, and its prevalence is continuously rising affecting the quality of life of people with the disease and their life expectancy. It also imposes a heavy burden to the national health care budget and on the economy in the form of productivity losses. Aims: To review and discuss a) the reported evidence on diabetes prevalence, the degree of control, the cost of care and outcomes, b) available strategies to decrease the health and economic disease burden, and c) how the disease fits in the Argentinian health care system and policy. Finally, to propose evidence-based policy options to reduce the burden of diabetes, both from an epidemiological as well as an economic perspective, on the Argentinian society. The evidence presented is expected to help the local authorities to develop and implement effective diabetes care programmes. Methodology: A comprehensive literature review was performed using databases such as MEDLINE, EMBASE and LILACS (Latin American and Caribbean Health Sciences). Literature published from 1980 to 2011 was included. This information was complemented with grey literature, including data from national and provincial official sources, personal communications and contacts with health authorities and diabetes experts in Argentina. Results: Overall diabetes prevalence increased from 8.4% in 2005 to 9.6% 2009 at national level. In 2009, diabetes was the seventh leading cause of death with a mortality rate of 19.2 per 100,000 inhabitants, and it accounted for 1,328,802 DALYs lost in the adult population, mainly affecting women aged over fifty. The per capita hospitalisation cost for people with diabetes was significantly higher than for people without the disease, US$1,628 vs. US$ 833 in 2004. Evidence shows that implementation of combined educative interventions improved quality of care and outcomes, decreased treatment costs and optimised the use of economic resources. Conclusions: Based on the evidence reviewed, we believe that the implementation of structured health care programmes including diabetes education at every level, could improve quality of care as well as its clinical, metabolic and economic outcomes. If implemented across the country, these programmes could decrease the disease burden and optimise the use of human and economic resources.Fil: Caporale, Joaquin E.. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); Argentina. Universidad Nacional de la Plata. Facultad de Ciencias Médicas; ArgentinaFil: Elgart, Jorge Elgart. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); Argentina. Universidad Nacional de la Plata. Facultad de Ciencias Médicas; ArgentinaFil: Gagliardino, Juan Jose. Consejo Nacional de Investigaciones Científicas y Técnicas. Centro Cientifico Tecnológico La Plata. Centro de Endocrinologia Experimental y Aplicada (i); Argentina. Universidad Nacional de la Plata. Facultad de Ciencias Médicas; Argentin