ORGANIZATION OF CARE :ORGANIZATION OF CARE : SPECIFICITIES OF THE SPECIFICITIES OF THE

MEDITERREAN REGION.MEDITERREAN REGION.THE EXPERIENCE OF ALGERIATHE EXPERIENCE OF ALGERIA..

A. BOUDIBA. HUC ALGIERSA. BOUDIBA. HUC ALGIERS

2381 741Km2

85% Sahara

32. 400.000 population (2004)

52,7% < 25 years 5,1% > 65 years

GBRGBR GDRGDR NGR (Pour 1000)NGR (Pour 1000)

19801980 43,943,9 11,811,8 32,132,1

19901990 31,031,0 6,06,0 2525

20042004 20,420,4 4,54,5 15,815,8

• GBR: Gross birth rate

• GDR: Gross death rate

• NGR: Natural growth rate

48 Wilayas / 548 Dairas / 1541 municipalities

185 Health districts (100 / 200.000 people)

13 HUC 1252 3964 Private sector

SHC Health centers health care (privately owned

rooms sector strong

growth : specialists (58%)

DIABETES CARE MANAGEMENT DIABETES CARE MANAGEMENT

GOVERNMENT ENTITIES « Awareness »• Health Department/Prevention Direction/national diabetes committee• National program against non transmissible diseases• 8 risk factors (tobacco, alcohol drinking, obesity, sedentariness,

, high blood pressure, hypercholesterolemia, diet)

TREATMENT « Problem of networks »

PRIMARY LEVEL SECONDARY LEVEL TERTIARY LEVELHealth Centers Diabetics Homes HUC General Physicians Polyclinics Regional Hospitals

Technical Equipments not sufficient Basic Specialists

Private Sector

Diabetes

SOCIAL

• Social care security (Free medical care / Reimbursement…)

• Associations / National Diabetes Federation

• Social protection and Solidarity Department.

« Economic transition »

FORMATION - RESEARCH« Diabetes and vascular Risk option »

• Formation Centers : Endocrinology, Diabetology, Internal Medicine

• Research : - Clinical Epidemiology :Many post graduate oriented towards

diabetes

- Fundamentals : University of Sciences and Technology (biology/

animal physiology : Experimental model …Psammomys obesus )

- Immunology…

• Financing sources insufficient : SRNA (Scientific Researches National Agency),

Universities, Health Ministry).

RISK FACTORS ASSOCIATED WITH RISK FACTORS ASSOCIATED WITH TRANSMISSIBLE DISEASES TRANSMISSIBLE DISEASES **

Mostaganem (M) (2140) 4136 Sétif (S) (1996)

MM SS T(%)T(%)

TobaccoTobacco 23.423.4 2828 25.625.6

AlcoholAlcohol 8.18.1 4.24.2 6.26.2

Fruits/vegetablesFruits/vegetables< 5parts< 5parts

60.660.6 49.949.9 55.355.3

SedentarinessSedentariness 3131 11.811.8 21.621.6

0besity0besity 20.920.9

DiabetesDiabetes 5.95.9 8.88.8 7.37.3

socio-eco level. socio-eco level. - Low - Low

- Average- Average - High - High

42.142.150.950.97.37.3

26.926.960.560.512.612.6

34.634.655.555.59.99.9

**

* Methodology « Step wise OMS ». 2004 - Known = 2.5% - Screened = 4.8 % ** - 5.5% (25 – 54 years) - 13.7% (55 – 60 years) ID. R. MALEK, 2001

DIETETICSDIETETICS

• Dieteticians very insufficient ? • National inquiry TAHINA (Transition Health Impact in North Africa)*

Feculents (3.84) Bread 2.14 Potatoes 0.91 Pasta 0.63 Couscous 0.3

Dairy products 1.28

Vegetables 0.83

Sugar products/Sodas 0.62

Fruits 0.53

Meats products/proteins Eggs 0.43Meats 0.19Poultry 0.15Fish 0.14 (< 0.06) Country side

Fats Olive oil 0.44Others 1.3

* National Public Health Institute 2006

HEALTH NETWORKS ORGANISATION HEALTH NETWORKS ORGANISATION 3 REGIONAL POLES 3 REGIONAL POLES

WEST / 18 Wilayas (W) CENTRE / 12 W EAST / 18 W

1 NETWORK / HEALTH SECTOR* ~ 100.000/200.000/

Screening (2006) / AG** - BP Care offer Education FormationWest (~ 190.000 ~ 10% - 18.3% Access / Availability RecommendationsCentre (~ 141.000 ~ 11% - 19.2% Easy pathway UniformisationEast (~ 90.000 ~ 7.7%

COMPONENTS : - Health professionals / Doctors – Paramedics - Patients of the health district STRUCTURES : - Referential ─ HUC / Internal Medicine - Diabetology - Reception sites ─ Diabetes home / Polyclinics… OBJECTIVES : ~ 3 years

- Phase I ─ Implementation patient’s file sharing (minimal data)

- Phase II ─ Evaluation of medical Audits practices and behaviors. - Phase III ─ Optimization Recommendations

* M. BROURI. Algiers Reevaluation **AG : Abnormal Glycemia

PRIMARY PREVENTIONPRIMARY PREVENTION « Determination of a predictives score »*« Determination of a predictives score »*

n = 1500n = 1500Priliminary results (297)**Priliminary results (297)**

NGT (175)

IFG(9)

IGT(61)

DM(52)

Age (years) 46.61(10.05)

51.21(11.23)

(53.62)(10.40)

< 0.001

Heredity 33 67% 65 < 0.01

BMI 23.11 28.81(5.74)

28.64(4.55)

< 0.001

HBP (%) 11.42 31% 34% < 0.001

Metab. Syndrome. 17% 56% 65% < 0.001

Triglyceride (g/l) 1.25(0.68)

1.38(0.72)

1.55(0.76)

< 0.01

HDL (g/l) 0.48(0.10)

0.50(0.11)

0.45(0.12)

ALAT (UI/l) 17.05(9.07)

48.24(10.7)

50.88(13.81)

< 0.001

Walking > 30’/d 1.12(0.79)

0.82(0.56)

0.86(0.6)

Green vegetables / Week 6.00(2.48)

6.95(3.03)

6.67(3.72)

Fruits / Week 6.44(3.29)

5.51(2.45)

6.65(3.22)

Fish / Week 1.42(1.09)

1.17(0.43)

1.32(1.19)

* LINDRSTRÖM J. TUOMILEHTO J. The diabetes risk score. A practical tool to predict type 2 diabetes risk. D. care 2003, 26, 725-731.* Implementation of the national type 2 diabetes prevention TUOMILEHTO J. IDF 2006. ** M. AZZOUZ, A. BOUDIBA. Algiers.

PREVENTION : PREVENTION : RISK FACTORS OF THE RISK FACTORS OF THE GESTATORY DIABETESGESTATORY DIABETES

Profile of the Algerian Pregnant woman with GD risk*Profile of the Algerian Pregnant woman with GD risk*

Controls (300) Cases (150)

Anterior macrosomia 7% 33% +(OR=3.67 ; 1.91<IC<7.05)

BMI > 25 14% 31% +(OR=3.10 ; 1.91<IC<5.03)

Low social economic level

9% 26% +(OR=2.53 ; 1.34<IC<4.47)

Family diabetes history

25% 58% +(OR=1.94 ; 1.38<IC<3.53

Multiparity ≥ 3 40% 69% +(OR=1.88 ; 1.15<IC<3.08)

Age > 30 / ATCD T2D / Insulinotherapy during pregnancy Decisive factors of the persistance of post-partum diabetes. Obesity / Age > 30 / Insulinotherapy during pregnancy showing GD high risk factors of recurency*** S. MIMOUNI – A. BOUDIBA.** M. BACHAOUI – M. BELHADJ.

PREVENTION : DIABETIC FOOTPREVENTION : DIABETIC FOOT • Problem : - 10% - 30% hospitalizations : 55% bed occupancy rate

- Amputations : 2001-2005 (decrease 31%) - Podologists / Revascularition surgery : do not exist ?

• Prevention recommendations – education : reinforcement at all levels • Projections I PRELIMINARY RESULTS* PODOSCOPY Organ risk normal F Hallow Flat Anatomic condition 54% 38% 8% RECOMMANDATIONS Good Average BadFootwear 30% 52% 18%Hygiene 63% 32% 5%Education Level 21% 46% 33% Of the patient

Regular foot 39%Check up

LÉSION STATUS

Clinic N = 48% Neurologic = 32% Ischemic = 6% Mixte = 14%EchoDoppler N = 42% Pathologic = 58% - Atherosclerosis 44%

- Mediacalcosis 39% - Atheromatosis + Stenosis 7% Projections II (Algerian Society of Vascular Medecine**) prevention / Preservation treatment / Decrease of amputations.* S. AOUICHE, A. BOUDIBA – Diabetology Algiers. ** M. BROURI – UHC Birtraria Internal Medecine Algiers.

vulnerability score

SAMEV creation

MEDICAL CARE /SECONDARY LEVELMEDICAL CARE /SECONDARY LEVEL

Exemple «Diabetic Home»Exemple «Diabetic Home»~ 30 000 Check up/year~ 30 000 Check up/year

Clinical practice evaluation 2005 Clinical practice evaluation 2005

• HbA1c > 1/an 30% 1f/an 70%

• Retinal screening 85%• ECG 70%• Lipids (TC – Trig.) 95%• HDL/LDL 20%• Micro albuminuria 21%• Vascular Doppler 22%• Foot care 30% • Educators/dieteticians : 8 (2 sessions/day)• Psychologists : 2

TYPE 2 DIABETES MEDICAL CARE EVALUATIONTYPE 2 DIABETES MEDICAL CARE EVALUATION«Diabetics Home in Algeria»«Diabetics Home in Algeria»

Number 2001 2005Number 2001 2005 934 1689934 1689Average follow up (year) 9.39 Average follow up (year) 9.39 6.86 6.91 6.86 6.91 6.65 6.65Overweight BMI > 25-30 35% 43%Overweight BMI > 25-30 35% 43%Obesity > 30 25% 29% Obesity > 30 25% 29% BP 50.8% 67% BP 50.8% 67% SBP - 13.44 SBP - 13.44 2.19 2.19 DBP - 7.87 DBP - 7.87 1.16 1.16Cardiovascular events 22% 29% Cardiovascular events 22% 29% Abnormal ECG 20% 36% Abnormal ECG 20% 36% Retinopathy 33% 27% Retinopathy 33% 27% Périphéric neuropathy 45.8% 54%Périphéric neuropathy 45.8% 54%Néphropathy 27% 24% Néphropathy 27% 24% HbA1c ≤ 7%HbA1c ≤ 7%Trig > 1.5 g/l 29% 28% Trig > 1.5 g/l 29% 28% T Chol. > 2 g/l 32% 34% T Chol. > 2 g/l 32% 34% Insulin secretor agents 65% 49% Insulin secretor agents 65% 49% Biguanid Biguanid InsulinothérapyInsulinothérapyCEICEI

ARAII ARAII -- 16% 16%

.blocking 21% 26% .blocking 21% 26% Diurétics 11% 21% Diurétics 11% 21% Calcium inhibitors 17% 23%Calcium inhibitors 17% 23%Lipid lowering drugsLipid lowering drugs

cms/Hg

11% 23%11% 23%

28% 39%

42% 51%

11% 27%

27% 35%

5400

Hea

lth A

ssoc

iatio

ns

To sum up, they consist, inter alia, into thecreation of a «national fund» dedicated to ill People; to listen to and evaluate the waiting time to access medical care; to bring closer quality care services to citizens where they live, to repertoriate ; chronic ill people in order to be able to respond with quality medical care and allow for real treatment opportunities to happen. Dj. K

To sum up, they consist, inter alia, into thecreation of a «national fund» dedicated to ill People; to listen to and evaluate the waiting time to access medical care; to bring closer quality care services to citizens where they live, to repertoriate ; chronic ill people in order to be able to respond with quality medical care and allow for real treatment opportunities to happen. Dj. K

25 mars 200725 mars 2007

BETWEEN RECOMMENDATIONS ..… AND MEDICAL PRACTICE

PATIENT PHYSICIAN HEALTH SYSTEM

- Socio- économic level - Cost - Complexity- Priorities

- Motivation- Rémuneration work place - Education - Attitudes

- Organisation - Transition Public/Private- Ressources - Spécialized staff- Equipments

Therapeutic alliance= Bypass / supress hurdles*- Care offers / Easy way - Realistic messages / simple / rehabilitation of mediterranean diet - General physician rehabilitation. - Appropriate recommendations / act on modifiable constraints**

* Euro-Obstacles * VENKAT NARRAYAN KM et Al. Translation research for chronic disease. The case of diabetes. Diabetes care 23, 12, 1794-98, 2000.** H. ALBERTI, N. BOUDRISSA. Primary care of patients with diabetes mellitus in Tunisia qualitative study of barriers and facilitators to care (IDF 2006).

DISEASE

- Diet/ exercice- Métabolic Syndrom« anti hyperglycemic objectives drown- Multidisciplinairy Relays with little efficiency

« Death is anavoidable, but a lasting

bad health is not»

FID 2006.