Epidemiology of Diabetes Mellitus and Main Directions for Improving Diabetological Care for the Population at the Regional Level (on the Example of Amur Oblast)

The dissertation is dedicated to the comprehensive study of the epidemiology of diabetes mellitus and the development of directions for improving diabetological care at the regional level. The research was conducted on the example of Amur Oblast and covers the analysis of levels of prevalence of diabetes mellitus, its complications, disability, and mortality of the population, as well as socio-economic aspects of morbidity. Data from the regional register of diabetes mellitus were used in the work, the quality of life of patients was analyzed, and the need of the region for various types of specialized care was assessed.

Based on the conducted comprehensive analysis, a regional model for the organization of diabetological care and the system of management of a specialized service has been developed, including a predictive assessment of the effectiveness of implementing programmatic tasks using linear regression methods. The results of the research were implemented in the regional target medical program and are used in the educational process of the medical university.

The relevance of the research is determined by the increasing level of prevalence of diabetes mellitus and its numerous complications, which constitute the primary cause of disability and mortality among people in industrially developed countries. Over the past 30 years, the increase in diabetes mellitus prevalence has been 5–6% and shows a tendency toward further growth, primarily in age groups over 40. Every 10–15 years, the number of patients with diabetes mellitus doubles [6,7,8,54,55,66,181,190].

At present, diabetes mellitus is a paramount problem worldwide [52,60,198,241]. According to WHO estimates, the number of patients with DM globally amounts to 177 million, and by 2025 the contingent of patients is projected to increase to 300 million. In Russia, the number of patients with diabetes mellitus may increase fivefold by 2010 and reach 10 million [10,12,56,62,66,182].

The actual prevalence of type 2 DM exceeds the registered prevalence based on healthcare utilization by 2–3 times. In half of cases, type 2 DM is detected in the 5th–7th year of disease onset; therefore, at the time of diabetes diagnosis, 20–30% of these patients also have complications specific to the disease. All this determines its medical-social significance not only among other forms of diabetes but also among all chronic non-infectious diseases [10,51,52,57,63,197,210].

The great social significance of the problem lies in the fact that diabetes mellitus leads to early disability and mortality in connection with late vascular complications of diabetes, among which are microangiopathies (retinopathy and nephropathy), macroangiopathies (myocardial infarction, stroke, gangrene of the lower extremities), and neuropathies. Diabetes mellitus is a frequent cause of blindness, death from uremia, and the development of cardiovascular diseases. The risk of developing ischemic heart disease and myocardial infarction in DM increases more than 2-fold, kidney pathology — 17-fold, gangrene of the lower extremities — 20-fold, hypertensive disease — more than 3-fold. In 30% of patients with type 1 DM and 10–15% of patients with type 2 DM, vision loss is associated with diabetic retinopathy [7,9,55,57].

More than 40% of all non-traumatic lower extremity amputations are performed in connection with the diabetic foot syndrome and gangrene of the lower extremities. Distal polyneuropathy and autonomic neuropathy are causes of low quality of life, loss of work capacity, and disability among a large number of patients with diabetes mellitus.

Patients with diabetes mellitus require hospitalization more frequently than other patients; the direct costs of the healthcare system for patients with diabetes mellitus, including specialist time, medications, rehabilitation expenses, and others, are quite substantial [51,56,63,181,195]. All this underscores the social nature of the disease, which leads to enormous economic losses for society.

The absence of studies on the investigation of actual needs of the population of regions in various types of medical care does not allow for adequate planning of the development of healthcare services taking into account the actual needs of the population.

Solving the problem requires taking into account differences between regions, including studying the features of predisposition to the disease and factors contributing to the degree of accessibility of medical care and improving its organization.

At present, the emphasis is placed on the economic aspect of medical care. New medical technologies aimed at improving diagnosis and treatment, and achievements in medicine, open new possibilities in the provision of medical care; however, they also entail an increase in costs. In this connection, there arises a need for statistical and economic information to make decisions in favor of one form or another of medical service, to manage financial flows directed toward medical programs of specialized as well as cross-sectoral nature. In addition, scientific research is necessary for making decisions on the introduction of new treatment methods in diabetology, creating favorable conditions for people with diabetes, and optimizing healthcare resources.

Thus, the relevance of the problem is determined by the medical-social significance of diabetes mellitus, characterized by increasing levels of labor losses and economic damage as a result of morbidity, disability, and mortality of the population, as well as expenditures by the state and society directed toward treating the disease and its complications, which require improvement and enhancement of the effectiveness of the system of specialized, qualified care.

All of the above has determined the goal of the present work:

Based on the study of epidemiological and socio-economic aspects of disease prevalence among the population with diabetes mellitus, to develop the main directions for improving diabetological care at the regional level.

In accordance with the set goal, the following tasks were determined:

• To study the levels of prevalence of diabetes mellitus and its complications among various age-gender groups of the population and to identify epidemiological features of morbidity, disability, and mortality in modern socio-economic conditions at the regional level.

• To conduct a socio-economic assessment of the direct and indirect costs of society associated with the problem of diabetes mellitus.

• To investigate the quality of life of patients with diabetes mellitus.

• To determine indicators of the population's need for various types of diabetological care, the degree of its resource provision, accessibility, and efficiency.

• To develop a regional model for improving the organization of diabetological care for the population and the system of management of a specialized medical service.

Scientific novelty of the research.

The scientific novelty of the completed work is determined by the fact that, for the first time, based on the regional register of diabetes mellitus, a comprehensive socio-hygienic and epidemiological analysis of the levels and dynamics of disease prevalence among the population of Amur Oblast with diabetes mellitus, its main complications, and adverse outcomes has been conducted, and regional, territorial, and socio-economic features and statistical patterns of the spread of the pathology and its main manifestations have been identified.

For the first time, a socio-economic analysis of the problem of disease prevalence among the population with diabetes mellitus, which leads to severe complications of the disease, early disability, and premature mortality, has been conducted; an assessment of the direct and indirect costs of society and the state associated with providing medical-social care; and a socio-economic assessment of the effectiveness of using various models in the organization of specialized care.

For the first time, a study of the quality of life of patients with diabetes mellitus has been conducted using valid assessment instruments.

A comprehensive assessment of the resource provision (network, medical personnel, finances) of the diabetological service has been conducted under conditions of implementing the territorial program of state guarantees for providing medical care to the population and the degree of its effective use; norms of the population's need for various types of diabetological care have been developed, taking into account demographic and economic features, for its optimization.

Based on the diagnosis of internal and external factors of modern problems in diabetology and the methodology of systems analysis, the development of a regional model for the formation, development, and improvement of the organization of diabetological care for the population and the system of its effective management has been carried out. Using linear regression methods, a predictive assessment of the effectiveness of implementing programmatic tasks for the development of a prospective diabetological service model has been conducted.

Scientific and practical significance of the research.

The results of the comprehensive socio-hygienic and epidemiological analysis of disease prevalence among the population with diabetes mellitus and the socio-economic aspects of its adverse outcomes, as well as the assessment of the effectiveness of the specialized diabetological service, have substantial significance for medical science and practice and can be used in the healthcare management system and by specialists of the diabetological service.

As a result of the research, epidemiological and regional features of the spread of this pathology and its main consequences, as well as the quality of life of patients with diabetes, have been identified.

Data on the epidemiology of diabetes mellitus and its complications, and on socio-hygienic factors of the progressive growth of morbidity, have made it possible to develop the main directions for improving the organization and management of diabetological care at the regional level, to determine the actual need for personnel, material, and financial resources of healthcare, and to optimize the structure of the organization of the diabetological service.

In the process of implementing the work, a regional register of patients with diabetes mellitus has been developed, which serves as the basis for conducting active monitoring of morbidity, disability, and mortality of the population.

Based on the conducted research, norms of the population's and the diabetological service's need for healthcare resources have been developed to ensure optimization and improvement of the effectiveness of diabetological care; an organizational model for improving the structure of diabetological care and its effective management has been proposed.

Based on the materials of the scientific research, additions and changes have been introduced into the regional state target medical program «Prevention and Combating of Socially Significant Diseases for 2005–2008», aimed at reducing the levels of disease prevalence among the population of Amur Oblast with diabetes mellitus, its main complications, and adverse outcomes, and at improving the effectiveness of diabetological care for the population of Amur Oblast (implementation act attached).

As a result of the research, a methodological manual «Epidemiology of Diabetes Mellitus in the Territory of Amur Oblast» has been prepared and published, approved by the Department of Health of the Administration of Amur Oblast. Data on the prevalence of diabetes mellitus and its complications among the population of Amur Oblast in modern socio-economic conditions (2002–2005), causes of death, and demographic indicators characterizing the state of public health and the degree of social environmental factors have been presented to government authorities and healthcare management bodies based on the results of using the regional register and monitoring of diabetes mellitus in the territory of Amur Oblast.

The results of the conducted research are used in the educational process at the pre- and postgraduate levels of training in departments of public health and healthcare, and faculty therapy at the State Educational Institution of Higher Professional Education Amur State Medical Academy (implementation acts attached).

The medical, social, and economic significance of the research results lies in the fact that they make it possible, based on a comprehensive medical-social and economic assessment of the problem of diabetes mellitus, to develop scientifically substantiated organizational and methodological measures aimed at reducing the levels of morbidity, disability, and mortality of the population and improving indicators of public health.

Main provisions put forward for defense:

• In modern socio-economic conditions, a high level of prevalence of diabetes mellitus and its adverse consequences is observed.

• Diabetes mellitus entails significant socio-economic losses for the state and society and a reduction in the quality of life of patients.

• The medical-economic assessment of the resource provision of a specialized service is the basis for determining priority directions for improving the organization of medical care and developing the population's need for necessary resources.

• The basis for modernizing the management of the system of care for patients with diabetes mellitus and improving the organization of diabetological care is the program for the prospective development of the service and a regional organizational model of specialized care.

Testing of the work.

The main provisions of the dissertation were reported and discussed at the IV, V, and VI regional inter-university scientific-practical conference «Youth of the XXI Century: A Step into the Future» (Blagoveshchensk, 2003, 2004, 2005), the Fifth International Scientific-Practical Conference «Health and Education in the XXI Century» (Moscow, 2004), and the Interregional Scientific-Practical Conference «Problems and Prospects of Formation and Development of the System of Management of Ensuring Quality of Medical Care» (Kemerovo, 2004).

Publications.

18 printed works have been published on the topic of the dissertation research, including 4 in international publications, 1 in publications reviewed by the VAK RF, and 1 methodological manual.

Scope and structure of the work. The dissertation consists of an introduction, 5 chapters, conclusion, summaries, proposals and recommendations, list of references, and appendices. The work is presented in 198 pages of main text, illustrated with 47 tables and 29 figures. The list of references used includes 250 sources, including 180 domestic and 70 foreign authors.