Cosas que importan a los

pacientes con diabetes.

Expectativas, promesas y

realidades.

Dr. José Manuel Millaruelo TrilloMédico de familia.

Centro de Salud Torrero La Paz, Zaragoza

¿Qué esperáis de este taller?

• ¿Qué es lo que sabemos? ¿Por qué?

• ¿Qué tipo de información tienen los pacientes? ¿De quien la reciben? ¿Qué saben?

• ¿Son las mismas cosas que preocupan a los médic@s?

¿Qué hacemos en la primera visita de diagnóstico

de diabetes?

•Decirles con que criterio hemos diagnosticado de diabetes

•Hablarles de la cronicidad de la enfermedad

•Insistir en la necesidad de un buen control metabólico

•A veces, también del buen control del resto de factores de riesgo

•La necesidad de dieta y ejercicio

•Derivar a la consulta de enfermería para (muchas veces) mas de lo mismo

¿Qué hacemos en la primera visita de diagnóstico de

diabetes? Y si somos unos “fenómenos”?•Preguntar que conocen de la diabetes

•Preguntar si tienes familiares o amigos que viven con la diabetes

•Preguntar si conocen las complicaciones de la diabetes

•Preguntar aspectos de su vida diaria: alimentación, trabajo, ocio

•Preguntar que saben de la alimentación (distinguir principios inmediatos…)

•Preguntar si saben los síntomas de una hipoglucemia

•¿Y sus preocupaciones?

•Que les preocupa de tener diabetes

¿Cómo son los objetivos que interesan a los médicos?

Biológicos para (en teoría) evitar

complicaciones

¿Como son los objetivos que interesan a los pacientes?

¿Se cura la diabetes?•Los relacionados con el día a día de la enfermedad

•Los relacionados con los cambios de hábitos que tendrán que hacer (dieta, ejercicio)

•Los relacionados con cambios en conductas sociales (comidas, viajes)

Primary care-led weight management for remission of type 2 diabetes

https://doi.org/10.1016/S0140-6736(17)33102-1

Primary care-led weight management for remission of type 2 diabetes

All

(n=306)

Intervention group

(n=157)

Control group

(n=149)

Number of serious adverse events 11 9 2

Number of participants with any

serious adverse event9 (3%) 7 (4%) 2 (1%)

Cardiac disorders* 1(<1%) 1(1%) 0

Angina pectorist 1(<1%) 1(1%) 0

Gastrointestinal disorders* 2(1%) 2(1%) 0

Abdominal paint† 1(<1%) 1(1%) 0

Abdominal strangulated hermiat 1(<1%) 1(1%) 0

Cholelithiasist† 1(<1%) 1(1%) 1(1%)

Infections and infestations 2(1%) 1(1%) 0

Urinary tract infection† 1(<1%) 1(1%) 1(1%)

Wound infection† 1(<1%) 0 1(1%)

Injury, poisoning and procedural

complications*2(1%) 2(1%) 0

Incisional hernia† 1(<1%) 1(1%) 0

Synovial rupture† 1(<1%) 1(1%) 0

Nervous sustem disorders* 2(1%) 1(1%) 1(1%)

Dizziness† 1(<1%) 1(1%) 0

Presyncope† 1(<1%) 1(1%) 0

Seventh nerve paralysis† 1(<1%) 0 1(1%)

Data are n(%). *Classified by Medical Dictionary for Regulatory Activities system organ class. †Classified by preferred term.

Table 3. Serious adverse events

¿Y qué les preocupa a los investigadores?

¿Y que les preocupa a los investigadores?

PanelTop ten priorities for research in type 2 diabetes, in rank order of priority

1. Can type 2 diabetes be cured or reversed, what is the best way to achieve this, and is there a point beyond which the condition cannot be reversed?

2. How do we identify people at high risk of type 2 diabetes and help to prevent the condition from developing?

3. What is the best way to encourage people with type 2 diabetes, whoever they are and wherever they live, to self-manage their condition, and how should it be delivered?

4. How do stress and anxiety influence the management of type 2 diabetes and does a positive mental wellbeing have an effect?

5. How can people with type 2 diabetes be supported to make lifestyle changes to help them to manage their condition, how effective are these lifestyle changes, and what stops

them from working?

6. Why does type 2 diabetes get progressively worse over time, what is the most effective way to slow or prevent progression, and how can this be best measured?

7. Should diet and exercise be used as an alternative to drugs for the management of type 2 diabetes, or alongside them?

8. What causes nerve damage in people with type 2 diabetes, who does it affect most, how can we increase awareness of it, and how can it be best prevented and treated?

9. How can psychological or social support be best used to help people with or at risk of type 2 diabetes, and how should this be delivered to account for individual needs?

10. What role do fats, carbohydrates, and proteins have in the management of type 2 diabetes, and are there risks and benefits associated with particular approaches?

Tratamiento individualizado y por el beneficio

Objetivos actuales de tratamiento en la DM2

¿Son similares? ¿Son compatibles? O….

Actitudes, deseos y necesidades de las personas con

diabetes (DAWN2) 'diabetes tipo 3'

-63% de los familiares mostraron preocupación porque en un futuro su pariente desarrolle

complicaciones.

-66% tiene temor que sufran una crisis de hipoglucemia durante las noches.

-34% sufre un impacto financiero por lo costoso del tratamiento

-20% comenta que su familiar con Diabetes ha sufrido discriminación por padecerla.

-35% acepta haber tenido problemas con el paciente, por la forma cómo lleva su Diabetes

-75% de las personas no han recibido educación diabetológica suficiente…

Datos del Ladydiab

• Información: los participantes refieren una gran satisfacción (se sienten bien informados/as) y se sienten bien atendidos/as.

• No obstante, manifiestan inseguridad personal para generar preguntas sobre la enfermedad o sobre sus aspectos emocionales, por consideración a la falta de tiempo en la consulta o la falta de disponibilidad de los profesionales.

• Algunos pacientes demandan a los profesionales más recursos para complementar la información recibida en su día a día.

• Además, consideran que es necesario un vocabulario menos técnico y mejor acceso al especialista.

• Las personas participantes consideran que el profesional debe motivar y que el tono duro y alarmista no ayuda al buen automanejo de la DM2.

The Use of Language in Diabetes Care and Education

• is neutral, nonjudgmental, and based on facts, actions, or physiology/biology

• is free from stigma

• is strengths based, respectful, inclusive, and imparts hope

• fosters collaboration between patients and providers

• is person centered

Diabetes Care 2017;40:1790-1799

Vamos a preguntarles

• “Tener que tomar muchas pastillas y, tal vez, insulina”

• “Me ha hecho sentir enferma, inservible, vieja” “Que me vean así los demás”

• “Perder libertad, de comidas, de horarios” “Se acabaron los dulces, mis favoritos!! No sé que haré…”

• “Que me muera antes de hora” “Quiero ser abuela y a este paso no sé si llego…”

• “Que me quede inútil y me tengan que cuidar”

• “Estar siempre de médicos, esperas, colas,..”

• “Tener que ingresar en el Hospital. Es horrible!!

• “Me influirá en el trabajo…Tendré que faltar…Me echarán?”

• “Me engordaré aún más, todos están gordos”

• “Mi mujer no me dejará en paz…”

• “Tendré que engañar al médico. Es severo, pero buen médico”

Podríamos decir que…

•Los pacientes tienen distintos objetivos a los nuestros

•Que no conocemos demasiado los suyos

•Que no conocen muy bien las complicaciones y sus causas

•Que obtienen información de fuentes no muy fiables

•Que nosotros somos fuente de información y consejo

Clinicians’Expectations of the Benefits and Harms ofTreatments, Screening, and Tests A Systematic Review

JAMA Intern Med. 2017;177(3):407-419

JAMA Intern Med. 2017;177(3):407-419

Clinicians’Expectations of the Benefits and Harms ofTreatments, Screening, and Tests A Systematic Review

¿Por qué tenemos una mirada sesgada?

• Porque nos alegran las “buenas noticias”

• Porque sabemos poca estadística

• Porque no tenemos tiempo de mirar los artículos a fondo

• Porque es difícil ser “salmón”

• Porque creemos más en números y en imágenes que en las repercusiones de los procesos cognitivos

Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease

N Engl J Med 2017;376:1713-22

No. at Risk

Placebo 13,779 13,251 13,151 12,954 12,596 12,311 10,812 6926 3352 790

Evolocumab 13,784 13,288 13,144 12,964 12,645 12,359 10,902 6958 3323 768

Absolute difference (mg/dl) 54 58 57 56 55 54 52 53 50

Percentage difference 57 61 61 59 58 57 55 56 54

P value <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001

Evolocumab and Clinical Outcomes in Patients with Cardiovascular Disease

N Engl J Med 2017;376:1713-22

No. At Risk

Placebo 13,780 13,278 12,825 11,871 7610 3690 686

Evolocumab 13,784 13,351 12,939 12,070 7771 3746 689

No. At Risk

Placebo 13,780 13,449 13,142 12,288 7944 3893 731

Evolocumab 13,784 13,501 13,241 12,456 8094 3935 724

Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes

N Engl J Med 2015;373:2117-28

No. At Risk

Empagloflozin 4587 4580 4455 4328 3851 2821 2359 1534 370

Placebo 2333 2256 2194 2112 1875 1380 1161 741 165

No. At Risk

Empagloflozin 4687 4651 4508 4556 4128 3079 2517 1722 414

Placebo 2333 2303 2280 2243 2012 1503 1281 825 177

No. At Risk

Empagloflozin 4687 4651 4608 4556 4128 3079 2517 1722 414

Placebo 2333 2303 2280 2243 2012 1503 1281 825 177

No. At Risk

Empagloflozin 4687 4614 4523 4427 3988 2950 2487 1634 395

Placebo 2333 2271 2226 2173 1932 1424 1202 775 168

Desconocimiento de la enfermedad Valoración adecuada de los riesgos

¿Cómo llegar a un consenso?

•Alguien sabe que es la “atención centrada en el paciente”?

•Pensáis que practicamos “la atención centrada en el paciente”?

•En qué aspectos?

•Estamos dispuestos?

Picker’s Eight Principles of Patient Centred Care

Is Patient-Centered Care the Same As Person-Focused Care?

Barbara Starfield The Permanente Journal/ Spring 2011/ Volume 15 No. 2

Table 1. Differences between patient-centered care and person-focused care

Patient-centered care Person-focused care

Generally refers to interactions in visits Refers to interrelationships over time

May be episode oriented Considers episodes as part of life-course

experiences with health

Generally centers around the management of

diseases

Views diseases as interrelated phenomena

Generally views comorbidity as number of chronic

diseases

Often considers morbidity as combinations of types

of illnesses (multimorbidity)

Generally views body systems as distinct Views body systems as interrrelated

Uses coding systems that reflect professionally

defined conditions

Uses coding systems that also allow for specification

of people´s health concerns

Is concerned primarily with the evolution of

patients´diseases

Is concerned with the evolution of people´s

experienced health problems as well as with their

diseases

10 Guiding Principles for Patient-Centered Care

1. All team members are considered caregivers

2. Care is based on continuous healing relationships

3. Care is customized

4. Knowledge and information are freely shared

5. Care is provided in a healing environment

6. Families and friends are part of the care team

7. Patient safety is a visible priority

8. Transparency is the rule in the care of the patient

9. All caregivers cooperate with one another

10. The patient is the source of control for their care

5 Guiding Principles for Patient-Centered Care

1. All team members are considered care givers.

2. Care is based on continuous healing relationships.

3. Care is customized and reflects patient needs, values, and choices.

4. Knowledge and information are freely shared between and among,

patients, care partners, physicians, and other care givers.

5. Care is provided in a healing environment of comfort, peace, and

support.

Clinical and Patient-Centered Outcomes in Obese Patients With Type 2 Diabetes 3 Years After Randomization to Roux-en-Y Gastric Bypass Surgery Versus IntensiveLifestyle Management

Diabetes Care 2018;41:670–679

Implementation of a Structured Diabetes Consultation Model to Facilitate a Person-Centered Approach

Diabetes Care 2018;41:688–695

Step 1Discussing factors that influence goals,

treatment options and professional support

with the patient

Patient´s life related factors:

▪ Age

▪ Educational level

▪ Ethnicity

▪ Stage of life

▪ Quality of life

▪ Lifestyle

▪ Pregnancy (wish)

▪ Illness perceptions

▪ Motivation

▪ Patient´s preferences

▪ Self-management:

• knowledge and skills

• self-confidence

• opportunities for development

▪ Social context: home, school, wor, “leisure

time”

Health related factors:

▪ Glucose control

▪ Cardiovascular risk factors

▪ Complications

▪ Comorbidity

▪ Disease duration

▪ Hereditary factors

▪ Medication use

▪ Results of previous treatments

Step 2Setting personal and health

related goals together

Based on:

▪ Results of step 1

▪ Guidelines

Step 3Discusssing treatment

options to reach the goals

and making decision

Based on:

▪ Results of steps 1 and 2

▪ Guidelines

▪ Expert (center)

Step 4Assessing professional

support

Based on:

▪ Results of steps 1, 2 and

2

Support of:

▪ Physicians

▪ Paramedics

▪ Pharmacist

▪ Lifestyle coach

Consultation

mod

el

Estadísticamente significativo o clínicamente relevante. Hablamos de riesgos

RRR RRA

Incongruencia o contradicción

¿Por qué se utilizan como objetivos de tratamiento

cifras que no han demostrado mejorar la evolución

de las complicaciones?

Si lo que nos preocupa es lo macrovascular, ¿por

qué utilizamos para los objetivos las cifras de lo

microvascular?

Summary of the American College of Physicians Guidance Statement on HbA1C Targets for

Glycemic Control With Pharmacologic Therapy in Nonpregnat Adults With Type 2 Diabetes

Mellitus Disease/Condition Type 2 diabetes

Target Audience All clinicians

Target Patient Population Outpatient nonpregnat adults with type 2 diabetes

Outcomes Evaluated Microvascular and macrovascular outcomes, mortality

Benefits Reduced microvascular and macrovascular, reduced mortality

Harms Harms of achieving lower HbA1C targets with pharmacologic interventions included increasung hypoglycemia (including severe),

hospitalizations, weight gain, water retention, and death.

Adverse effects associated with pharmacologic treatments for diabetes include but are not limited to gastrointestinal side effects,

hypoglycemia, weight gain, congestive heart failure, joint pain, fractures, and genital mycotic infections. These adverse effects increase

with higher doses and greater numbers of medications likely required to achieve lower HbA1C levels.

Guidance Statements Guidance Statement 1: Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a

discussion of benefits and harms of pharmacotherapy, patients´preferences, patients´general health and life expectancy, treatment

burden, and cost of care.

Guidance Statement 2: Clinicians should aim to achieve an HbA1C level between 7% and 8% in most patients with type 2 diabetes.

Guidance Statement 3: Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve

HbA1C levels less than 6.5%.

Guidance Statement 4: Clinicians should treat patients with type 2 diabetes to minimize symptoms related to hyperglycemia and avoid

targeting and HbA1C level in patients with a life expectancy less than 10 years due to advanced age (80 years or older), residence in a

nursing home, or chronic conditions (such as dementia, cancer, end-stage kidney disease, or severe chronic obstructive pulmonary

disease or congestive heart failure) because the harms outweight the benefits in this population.

High-Value Care Deescalation of therapy, by reducing dosage or number of drugs, is warranted in many persons with HbA1C levels persistently <6.5% after

treatment with drugs. Persons with advanced age and lower life expectancy shoul be treat to reduce symptoms rather than strictly

focusing on specific HbA1C target levels.

Clinical Considerations Encourage a healthy lifestyle (e.g., tobacco cesation, diet and exercise, and attaining ideal body weight), including for risk reduction in

patients with known or high risk for cardiovascular disease.

Consider individual patient-level variables, such as polypharmacy issues, limited life expectancy, extensive multiple comorbid conditions,

and cognitive impairment.

Consider patient preference when deciding on treatment strategies and goals.

Test results for HbA1C levels can vary because of such conditions as anemia and chronic kidney disease; therefore, clinicians should aim

for a target range rather than a specific target.

Preguntar para saber,

Saber para comprender

Gracias