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JA-CHRODIS
WorkPackage7
Diabetes:acasestudyonstrengtheninghealth
careforpeoplewithchronicdiseases
Survey
onpracticesforpreventionandmanagementof
diabetes
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Table of Contents
Executivesummary
3
Acknowledgements
6
Introduction
8
Methods
9
Results
17
GeneralInformation 11
Preventionofdiabetesfocusonpeopleathighrisk
13
Managementofdiabetes
17
Educationprogramsforpersonswithdiabetesandtrainingforprofessionals
24
Educationprogramsforpersonswithdiabetes
24
Trainingprogramsforprofessionals
30
35
52
APPENDIX1-DataandnotesbyCountry APPENDIX2-Programs/experiencesreportedinthequestionnaires
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ExecutiveSummary
Thisreportpresentstheresultsofthesurveyonpracticesforpreventionandmanagement
of diabetes among the partners of the European Joint Action on Chronic Diseases and
Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS), and other countries not
involvedintheJA.
One of the main objective of JA-CHRODIS is to promote and facilitate a process of
exchange and transfer of good practices between European countries and regions,
addressingchronicconditions,withaspecificfocusonhealthpromotionandpreventionof
chronicconditions,multi-morbidityanddiabetes.IntheframeoftheJA-CHRODIS,diabetes
isconsideredacasestudyonstrengtheninghealthcareforpeoplewithchronicdiseases.
Theworkpackageondiabetes(WP7)focusesonallthemajoraspectsofaseriousdisease
like diabetes: identification of people at high risk, prevention and early diagnosis, health
promotion in people with diabetes, comprehensive multifactorial care, prevention of
complications, educational strategies for people with diabetes and training for health
professionals. To provide an overview on practices for prevention and management of
type2diabetes,theWP7teamconductedasurveyorganizedintwophases:thefirsthad
the objective to provide a structured overview about current programs (interventions,
initiatives, approaches or equivalents) that focus on aspects of primary prevention of
diabetes,identificationofpeopleathighrisk,earlydiagnosis,preventionofcomplications
of diabetes, comprehensive multifactorial care, education programs for persons with
diabetes and training for professionals; the second phase is devoted to an in-depth
analysisoftheprogramsidentifiedinthefirstone.
Thisreportpresentstheresultsofthefirstphaseofthesurvey.
Thesurveywasnotintendedtoprovideanexhaustivedescriptionofalltheactivitieson
diabetes in the participating countries, in fact the partners were asked to report plans,
programs, interventions, strategies, experiences that they felt worth to be reported and
shared.Implicitinthisactivityistheassumptionthatthedescriptionofexperiencesisan
effective means to make own experience available to others, and to create a capital of
knowledgethatcanbesharedandusedinthefuture.
Summaryresults
A total of nineteen countries, with 63 experts, contributed to the collection of data on
prevention and management of diabetes. Seventeen of them were involved in the JACHRODIS,RomaniawasreachedthroughEPF,andHungarybyitsrepresentativeintheJA
Advisoryboard.DatawerecollectedintheperiodDecember2014toApril2015.
ThedegreeofcompletenessvariedasafunctionoftheNationalpoliciesondiabetes,of
availabilityofdata,andofthepartnerwhofilledthequestionnaire.Asanexample,in
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BelgiumthequestionnairewasfilledinbytheEuropeanPatientForum,andreflectstheir
viewandknowledgeaboutBelgiancontext.InIreland,theEuropeanInstituteofWomen’s
Healthgaveitsoverviewonlyonpoliciesandinterventionsonpatienteducation.
Thirteen countries out of the 19 responders have a National Diabetes Plan and most of
themhavepoliciesandlegislationatnationallevelthatsupportdiabetesprevention,early
identification of people at high risk, education for persons with diabetes and training for
professionals. Early identification of people at high risk of diabetes too often lacks in
national policies. The education of people with diabetes and training for professional are
supportedbynationalpoliciesandlegislationbythe79%ofthecountriesevenif,insomeof
them, they don’t seem to be implemented, in fact no specific programs/interventions are
reported. In about two third of the countries (68.4%), the national information system
providesdataonprevalenceorincidenceofdiabetes.
ü
PREVENTIONOFDIABETES-FOCUSONPEOPLEATHIGHRISK
The role of prevention in the contrast of diabetes is stated fundamental. Type 2
diabetes, in particular, is preventable through lifestyle interventions, aiming at
relatively modest lifestyle changes, provided for people at high risk to develop the
disease.
In general, the importance of the prevention of diabetes is acknowledged and
addressed in policy level, as 3 out of 4 countries report that diabetes prevention is
supportedbynationalpoliciesandlegislations.However,earlyidentificationofpeople
atriskissupportedonlyby63.2%.Thismightindicatethatpreventionofdiabetesis
recognized at population level (e.g. advocating physical activity and healthy body
weightasmeanstopreventdiabetes)butspecificactionneedstargetedatpeopleat
riskarenotaddressedindiabetespoliciesinallcountries.
ü
MANAGEMENTOFDIABETES
Personswithchronicdiseasesrequirenotonlyeffectivetreatment,butalsocontinuity
of care, and adequate information and support, so that they can achieve selfmanagementtothegreatestpossibleextent.
Almostallthecountries,18outofthe19respondents,haveamanagementprogram
fordiabetes.About63.2%ofthemarestand-alonenationalprograms,and57.9%are
included in a more comprehensive national plan. Half of the participant countries
statedthattheprogramswereimplementedinthelast10years,andabout83%ofall
theimplementedprogramsarecurrentlyrunning.
Onlythe50%oftheprogramstakesintoconsiderationvulnerablegroups,e.g.ethnic
minoritiesandlowsocio-economicgroups.Definedcarepathwaysexisttodealwith
persons with diabetes, either with or at risk for micro- and macro vascular
complications,in77.8%ofthecountries.Mostoftheprograms(72.2%)aremonitored
through intermediate outcome indicators, 66.7% used process indicators and only
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44.4%long-termoutcomeindicators(Fig.B7).The16.7%ofthecountriesdidnotuse
anykindofindicator.
ü
EDUCATION PROGRAMS FOR PERSONS WITH DIABETES AND TRAINING FOR
PROFESSIONALS
Educationforpersonswithdiabetesisconsideredanintegralcomponentofdiabetes
care,andit'sintendedmainlytodevelopskillsinself-managementandcontributeto
the patient empowerment. Effective education provision needs trained health
professionals,withexpertiseineducationanddiabetesmanagement.
Onthewhole,15outofthe19participatingcountriesreportededucationprograms
forpersonswithdiabetes.Afewcountriesstatedtohaveaneducationprogramthat
exists in a stand-alone national program (15.8%), while 36.8% reported to have
education programs that are included in a more comprehensive National plan. The
core criteria of the quality of education programs are defined, e.g. the goal, the
rationale, the target group, the setting, the scheduling of the education sessions.
Morethanahalfreportedtohaveanevidence-basedcurriculumanddefinedspecific
education methods and didactics. Only the 60% reported that the curriculum is
evaluated, and a low number of the participating organizations (20%) reported that
long-termeffectindicatorswereused.
Training programs for professionals exist in two out of three of the participating
countries. The core criteria of the quality of training programs seem to be defined,
e.g., the goal, the rationale, the target group, the setting, the scheduling of the
training sessions. More than a half reported to have an evidence-based curriculum
and defined specific training methods and didactics. Only a low number (38.5%)
reported that a monitoring of effectiveness and quality of the training program is
defined. Less than a half reported that the training program is based on a theory
drivencurriculumandonlythe30.8%reportedthatintermediateoutcomeindicators
areappliedtomeasuretrainingprograms.
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Acknowledgments
ThisreportderivesfromtheEUJointActiononChronicDiseasesandHealthyAgeingAcross
theLifeCycle(JA-CHRODIS).
Thefollowingpartnerscontributedtothedevelopmentofthequestionnaire,thecollection
andanalysisofdata,andtodraftingtheReport:
Finland
JaanaLindström,KatjaWikström(THL).
Germany
UlrikeRothe,UlfManuwald(TUD).AndreaIcks,SilkeKuske(HHU).
Italy
MarinaMaggini,AngelaGiusti,FlaviaLombardo,BrunoCaffari(ISS).
Norway
MonicaSørensen(HOD)
Slovenia
JelkaZaletel(NIJZ)
Thefollowingpartnersandexpertscontributedtothecollectionofdataandtotherevision
oftheReport:
Austria
BrigitteDomittner,SabineHöfler(GÖG),ElisabethRappold,WolfgangGeißler,Martin
Robausch
Belgium
ValentinaStrammiello,VivianedeLavelaye(EPF)
Croatia
JosipCulig,MarcelLeppée(STAMPAR)
Cyprus
MyrtoAzina-Chronides(MoH),PaulosPaulou,GeorgiosOympios,MrsViviTreynor,Andreas
Stylianou
Finland
JaanaLindström,KatjaWikström(THL),TiinaLaatikainen
France
AlainBrunot(MoH),PierreGabbach,PierreFontaine
Germany
UlrikeRothe(TUD),AndreaIcks(HHU),ChristaScheidt-Nave,EckhardSalzsieder,Stefanie
Gerlach,BerndKulzer,MarionFellmann,StephanMager,Hans-JoachimVerlohren,Cornelia
Woitek,JensHofmann,JanSchulze,WolfgangBaier
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Greece
TheodoreVontetsianos,PanagiotouThemistoklis(YPE).AlaverasAntonios,NoutsouMarina
Hungary
PéterCsizmadia,KrisztinaFekete
Ireland
PeggyMaguire,MaeveCusack(EIWH)
Italy
MarinaMaggini(ISS),MassimoMassiBenedetti(HIRS),MarcoComaschi
Lithuania
ZydruneVisockiene(VUHSK),VytautasKasiulevicius,VidaAugustieniene
TheNetherland
FrancoisSchellevis(NIVEL)
Norway
MonicaSørensen(HOD)
Portugal
JoséManuelBoavida,CristinaPortugal(DGS)
Romania
CristianAndriciuc,IoanVeresiu,AncaMinea
Slovenia
JelkaZaletel(NIJZ)
Spain
AntonioSarríaSantamera,MariadelMarPolodeSantos(ISCIII),JesúsOlivaDomínguez
(MSSSI)
UK
DimitriVarsamis(NHS),NareshKanumilli
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Introduction
TheEuropeanJointActiononChronicDiseasesandPromotingHealthyAgeingacrossthe
Life Cycle (JA-CHRODIS) addresses the challenge of the increased burden that chronic
conditions and diseases place on the health systems and individuals. One of the main
objectiveofJA-CHRODISistopromoteandfacilitateaprocessofexchangeandtransferof
good practices between European countries and regions, addressing chronic conditions,
with a specific focus on health promotion and prevention of chronic conditions, multimorbidityanddiabetes.
In the frame of the JA-CHRODIS, diabetes is considered a case study on strengthening
healthcareforpeoplewithchronicdiseases.Diabetesisacommonandseriousdisease:it
increases the risk for many serious health problems (e.g, hypertension, cardiovascular
diseases, eye problems, neuropathy, foot complications, nephropathy), but can be
prevented and effectively controlled using available knowledge. With correct treatment
and recommended lifestyle changes, many people with diabetes are able to prevent or
delaytheonsetofcomplications.
Theworkpackageondiabetes(WP7)focusesonallthemajoraspectsofaseriousdisease
like diabetes: identification of people at high risk, prevention and early diagnosis, health
promotion in people with diabetes, comprehensive multifactorial care, prevention of
complications, educational strategies for people with diabetes and training for health
professionals. JA-CHRODIS is not a research project, thus its main objective is to use the
knowledgealreadyavailable,toimprovecoordinationandcooperationamongcountriesto
act on diabetes, including the exchange of good practices, and to create ground for
innovativeapproachestoreducetheburdenofchronicdiseases.Specialemphasisisalso
giventosupportthedevelopmentandimplementationofNationalDiabetesPlans.
Toprovideanoverviewonpracticesforpreventionandmanagementoftype2diabetes,
theWP7teamconductedasurveyorganizedintwophases:thefirsthadtheobjectiveto
provide a structured overview about current programs (interventions, initiatives,
approaches or equivalents) that focus on aspects of primary prevention of diabetes,
identification of people at high risk, early diagnosis, prevention of complications of
diabetes, comprehensive multifactorial care, education programs for persons with
diabetes and training for professionals; the second phase is devoted to an in-depth
analysisoftheprogramsidentifiedinthefirstone.Inthisreportwedescribetheresultsof
thefirstphaseofthesurvey.
Thesurveywasnotintendedtoprovideanexhaustivedescriptionofalltheactivitieson
diabetes in the participating countries, in fact the partners were asked to report plans,
programs, interventions, strategies, experiences that they felt worth to be reported and
shared.Implicitinthisactivityistheassumptionthatthedescriptionofexperiencesisan
effective means to make own experience available to others, and to create a capital of
knowledgethatcanbesharedandusedinthefuture.
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Methods
Thequestionnairewasorganizedin3sections:A-Preventionofdiabetes:focusonpeople
at high risk; B - Management of diabetes; C - Education programs for persons with
diabetesandtrainingforprofessionals.
Eachsectionwasdividedin3parts.Thefirstandsecondpartofeachsectionisdedicated
to a structured description of the main program (intervention, initiative, approach or
equivalent) at national, sub-national or local level. The third part of each section is
dedicated to a short description of other (up to 3) plans, programs, interventions,
strategies,experiencesthattherespondersfeltworthtobereportedandshared.Thelists
ofalltheprogramsarereportedintheAppendix2.
Thequestionnairewasdistributedtoallthepartners(associatedandcollaborating)ofJACHRODIS.Moreover,theEuropeanPatientForum(EPF,WP7associatedpartner)helpedin
findingexpertsfromcountriesnotinvolvedintheJA.Thepartnerswereinvitedtoidentify
and invite experts working on diabetes (e.g. experts from national, regional and local
healthinstitutesorpublicauthorities,associationsofpersonswithdiabetes,professionals
involved in the care of persons with diabetes, …) to contribute in filling in the
questionnaire. A web-based version of the questionnaire was available, thus the
responderscouldchoosewhichversion(pdforweb)touse.
In the countries were more than one partner was present, we asked to the partners to
workonauniquequestionnairetoprovideaCountryoverview.
Data were collected in the period December 2014 to April 2015. Data were summarized
andreviewedbyeachresponder.
Descriptiveanalysis
A summary descriptive analysis is done for each question indicating the frequency of
countriesbyeachresponseoption.Blankanswerswereconsideredas“No”.
Percentagesarecalculatedasthetotalofpositiveresponsesonthetotalofthecountries
involved in the survey. For the questions related to specific programs/interventions, the
analyseswererestrictedonlytocountriesthatreportedsomeofthem.
Each structured question is described by frequency tables and graphs (column and bar
charts).
AdetaileddescriptionwithdataandnotesbyCountryisreportedintheAppendix1.
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Results
A total of nineteen countries, with 63 experts, contributed to the collection of data on
prevention and management of diabetes. Seventeen of them were involved in the JACHRODIS,RomaniawasreachedthroughEPF,andHungarybyitsrepresentativeintheJA
Advisoryboard.
The degree of completeness varied as a function of the National policies on diabetes, of
availability of data, and of the partner who filled the questionnaire. As an example, in
BelgiumthequestionnairewasfilledinbytheEuropeanPatientForum,andreflectstheir
viewandknowledgeaboutBelgiancontext.InIreland,theEuropeanInstituteofWomen’s
Healthgaveitsoverviewonlyonpoliciesandinterventionsonpatienteducation.
Table1.Listofcountriesinvolvedinthesurvey
Partnership*
Country
Institution
Numberof
experts
§
involved CP
Austria
GesundheitÖsterreichGmbH(AustrianHealthInstitute)
5
AP
Belgium
EuropeanPatients'Forum(EPF)
2
CP
Croatia
AndrijaStampar(InstituteofPublicHealth)
2
CP
Cyprus
MinistryofHealthCyprus
5
AP
Finland
NationalInstituteforHealthandWelfare(THL)
3
CP
France
MinistryofHealth
3
AP
Germany
TechnischeUniversitätDresden(TUD)
Heinrich-HeineUniversity(HHU)
13
AP
Greece
"Sotiria''GeneralHospitalofAthens
4
MS
Hungary
NationalInstituteforHealthPromotion
2
AP
Ireland
EuropeanInstituteofWomen’sHealth(EIWH)
2
Italy
NationalInstituteofHealth(ISS)
3
AP
Lithuania
VilniusUniversity(VUHSK)
3
AP
Netherlands
NetherlandsInstituteforHealthServicesResearch(NIVEL)
1
AP
Norway
TheNorwegianDirectorateofHealth(HOD)
1
AP
Portugal
APDP-DiabetesPortugal
5
MS
Romania
RomanianFederationofDiabetesPersonsAssociations
3
Co-L
Slovenia
NationalInstituteofPublicHealth(NIJZ)
1
AP
Spain
AgencyforHealthTechnologyAssessment,National
InstituteofHealthCarlosIII(ISCIII)
3
CP
UnitedKingdom
NHSEngland
2
L
Total
19
63
*AP:AssociatedPartners.CP:collaboratingParners.L:Leader.Co-L:Co-leader.MS:MemberState.
§Thenumberofinvolvedexpertsincludesalsothecontactperson
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GeneralInformation
Thirteen countries out of the 19 responders have a National Diabetes Plan and most of
themhavepoliciesandlegislationatnationallevelthatsupportdiabetesprevention,early
identification of people at high risk, education for persons with diabetes and training for
professionals(Fig.1,Table2).Earlyidentificationofpeopleathighriskofdiabetestoooften
lacks in national policies. The education of people with diabetes and training for
professionalaresupportedbynationalpoliciesandlegislationbythe79%ofthecountries
even if, in some of them, they don’t seem to be implemented, in fact no specific
programs/interventionsarereported.
Inabouttwothirdofthecountries(68.4%),thenationalinformationsystemprovidesdata
on prevalence or incidence of diabetes, in 9 countries (47.4%) both the information are
available.
Figure1.Elementssupportedbynationalpoliciesandlegislations
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Table2.CountrywithaNationalDiabetesPlan(NDP)andelementssupportedbynational
policiesandlegislation
Legend:
• Yes
No/Data not available
NDP
Diabetes
prevention
Early
Educationfor
identificationof Diabetescare peoplewith
peopleatrisk
diabetes
Austria
•
•
•
Belgium
Croatia
•
•
Cyprus
•
Finland
Trainingfor
professional
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
France
•
•
•
Germany
•
•
Greece
•
•
•
•
•
•
Hungary
•
•
•
•
•
•
Ireland
Italy
•
•
•
•
•
•
•
•
•
•
•
•
•
Norway
•
•
•
•
•
•
•
Portugal
•
•
•
•
•
•
Romania
•
•
•
•
•
•
Slovenia
•
•
•
•
•
•
Spain
•
•
•
•
UnitedKingdom
•
13
•
•
•
•
•
14
12
17
15
15
Lithuania
Netherlands
Total:
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A-PREVENTIONOFDIABETES-FOCUSONPEOPLEATHIGHRISK
Theroleofpreventioninthecontrastofdiabetesisstatedfundamental.Type2diabetes,in
particular, is preventable through lifestyle interventions, aiming at relatively modest
lifestylechanges,providedforpeopleathighrisktodevelopthedisease.Thedevelopment
into overt diabetes can take many years, this “lag period” is an important window of
opportunityforpreventiveactions,andoffersthetimetopreventordelaythedevelopment
of diabetes among these individuals at risk. Therefore, interventions to prevent the
development of diabetes in these high-risk individuals should be an integral part of a
comprehensivediabetesplanandincludedinclinicalguidelinesfordiabetes.
Ingeneral,itseemsthattheimportanceofthepreventionofdiabetesisacknowledgedand
addressed in policy level, as 3 out of 4 countries report that diabetes prevention is
supported by national policies and legislations (Fig. A1). However, early identification of
peopleatriskissupportedbyfewer,only63.2%(Fig.1),thatmightindicatethatprevention
of diabetes is recognized at population level (e.g. advocating physical activity and healthy
bodyweightasmeanstopreventdiabetes)butspecificactionneedstargetedatpeopleat
risk are not addressed in diabetes policies in all countries. Slovenia has a stand alone
national diabetes program, and a parallel national program focusing on people at risk for
cardiovasculardiseases,thatincludespreventionofdiabetesandidentificationofpeopleat
high risk. In Belgium there are different programs in place at local, sub-regional, and subnationallevel,however,thecontentdoesnotvaryhugelyastheyarebasedoninternational
guidelinesandstandards.
Fig A1. Percentage of the countries having diabetes policies with specific prevention
targets
100
90
80
70
63.2
60
%
50
47.4
47.4
40
30
20
10
0
Stand-alonenational
program
includedinamore
comprehensiveNP
sub-national/locallevel
Note.Thesumofthepercentageisnot100%becausetheoptionsarenotmutuallyexclusive.Some
countries,asSpain,Cyprus,Croatia,UKandFinlandhaveastand-alonenationalprogramincludedin
amorecomprehensivenationalplan.
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Lithuania has not specific strategies for diabetes prevention, and Ireland (EIWH) didn’t
provideinformationonthistopic.Bothofthemwereexcludedfromthefollowinganalyses,
and the percentages are calculated using 17 countries as denominator, except for data
reportedinFigA2forwhichLithuaniaanswered.
Diabetes is known to affect disproportionately different social classes: people with lower
education or income are known to have higher prevalence of diabetes and some ethnic
groupsaremoreatriskthanothers.Thereforeitisofsomewhatconcernthat33.3%ofthe
countries respond that these “vulnerable” population groups are not taken into
considerationindiabetespreventionstrategies
Prevalenceofdiabetes,overweightandobesityandphysicalactivityarepublicinformation
availableatpopulationlevel(basedoneitherregistersorrepresentativesamples/cohorts),
but less frequently the countries have information on health care cost allocated to
preventionprograms(FigA2).
FigA2.Availabledataatpopulationlevel
100
Public
90
80
Onrequest
72.2
72.2
70
%
60
50.0
50
44.4
40
33.3
30
20
16.7
11.1
11.1
27.8
11.1
10
0
prevalenceof
diabetes
overweightand physicalactivity recommendation healthcarecost
obesity
onnutrition
allocated
Therespondentsarequiteconfidentthatthehealthcareprofessionalsintheircountriesare
well educated about basics of diabetes prevention, with 94.4% reporting “yes” to the
specific question. However, it is of concern whether this knowledge is implemented in
actual work at optimal level. The majority (82.4%) of countries have screening
protocols/guidelinesavailableforidentificationofhigh-riskpersons,butonlythe29.4%are
evaluated at population level. Validated diabetes risk assessment tools are available to
healthcare professionals in almost all (88.2%) the respondent countries. Multidisciplinary
approach to prevention, which is considered one of the cornerstones of efficacious
prevention, is reported by 76.5%, systems supporting prevention by 52.9%, and defined
care pathways for prevention by only 47.1% of respondents (Fig A3).
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FigA3.Availabletools
Validateddiabetesriskassessment to
healthcareprofessionals
88.2
Multidisciplinaryapproach
76.5
Informationtechnologysystemsathealthcare
providerlevel
52.9
Definedcarepathways
47.1
0
10 20 30 40 50 60 70 80 90 100
%
Statisticsontheprocessesrelatedtopreventiveactivitiesareingeneralseldomavailable,
about 1 in 10 countries reporting that they know how many high-risk individuals are
remitted to diagnostic procedures or lifestyle interventions, or achieving changes in risk
factors(Fig.A4).Furthermore,interventionsfordiabetespreventionoftenlackassessment
of individual’s risk factor profile and discussion of motivation for behavioural changes.
Aboutthehalfofthecountriesreportthatthestructureandcontentoftheinterventions,
individualizedtargets,orfollow-upplanaredefined(Fig.A5).
FigA4.Availabledataandstatistics
100
90
Public
80
Onrequest
70
%
60
50
40
30
23.5
20
10
0
5.9
11.8
0.0
11.8
0.0
11.8
0.0
5.9
11.8
5.9
11.8
screenedfor high-risk
high-risk droppingout achieving incidenceof
diabetesrisk individuals individuals
of
clinically
diabetes
remittedto remittedto interventions significant amonghighdiagnostic
lifestyle
changesin
risk
procedures interventions
riskfactors individualsin
interventions
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FigA5.Componentsofinterventionsfordiabetesprevention
assessmentofindividual'sriskfactorprofiles
64.7
discussionofindividual’smotivation for
behaviouralchanges
58.8
definitionofthestructureandcontentofthe
interventions
52.9
definitionofindividualizedtargetsforprevention
interventions
47.1
definitionoftheplanforfollow-up
47.1
0
10
20
30
40
50
60
70
80
90 100
%
Information on change in body weight is generally available as well as change in glucose
(76.5%)butonly41.2%reportthatinformationaboutchangeinnutritionisavailable(Fig.
A6).Thefrequentlackingofinformationofqualitymeasuresmightpreventtheevaluation
oftheeffectsofpreventiveactionsandthusbeabarrieragainstqualityimprovement.
FigA6.Informationavailableattheindividuallevel
weightchange
76.5
changeinglucoselevel
76.5
plannedvisitscompleted
64.7
changeinwaist circumference
52.9
changeinthequalityofnutrition
41.2
0
20
40
60
80
100
%
Four elements may be considered as the keys for an efficacious prevention of diabetes
amongpeopleatrisk:nationaldiabetespolicieswithspecificpreventiontargets,screening
protocol to identify high risk persons, defined care pathways and multidisciplinary
approach. Among the participating countries only 36.8% has all the four elements, the
percentagerisesto72.9%ifweconsideronly3oftheseelements.
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B-MANAGEMENTOFDIABETES
Persons with chronic diseases require not only effective treatment, but also continuity of
care,andadequateinformationandsupport,sothattheycanachieveself-managementto
thegreatestpossibleextent.Theevidencestronglysuggeststhattoimprovethequalityof
care for people with diabetes, and for most people with chronic diseases, we need to
reshapehealthcaresystemstofacilitatethetransitionfromfragmentationtointegrationof
care. A redesigned care system should include an organized multi component approach,
along with a real partnership between citizens and health professionals, and between
primaryandsecondarycare,soastoachievelong-termcoordinatedcarewithandaround
theneedsofpersonswithdiabetes.
About all the countries, 18 out of the 19 respondents, reported to have a management
programfordiabetes.About63.2%ofthemarestand-alonenationalprograms,and57.9%
are included in a more comprehensive national plan (Fig. B1). Some countries as Croatia,
Cyprus,Hungary,Finland,Italy,SpainandUKhaveastand-alonenationalprogramincluded
in a more comprehensive national plan; Austria and Greece has only programs at subnationalorlocallevel(Annex1-TableB1).Irelanddidnotprovideinformationonthistopic
andwasexcludedfromthefollowinganalyses.
FigB1.Percentageofcountrieswithadiabetesmanagementprogram
%
100
90
80
70
60
50
40
30
20
10
0
63.2
57.9
36.8
Stand-alonenational
program
includedinamore sub-national/locallevel
comprehensiveNP
Note. The sum of the percentage is not 100% because the options are not mutually exclusive. Some
countries as Cyprus, Croatia, Finland, Hungary, Italy, Spain and UK have a stand-alone national
program included in a more comprehensive national plan.
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The implementation level is mostly national (66.7%), in 38.9% regional and only in 33.3%
local.Fivecountriesreportedanimplementationatnational,regional,andlocallevel(Annex
1-TableB1).Thespreadwasurbanaswellasrural(Fig.B2).
FigB2.Implementationlevelandspread
77.8
83.3
66.7
%
100
90
80
70
60
50
40
30
20
10
0
33.3
local
38.9
regional
national
rural
urban
ImplementationlevelSpread
General practitioners are the health professionals mostly involved in the diabetes
management programs (94.4%) followed by nurses (83.3%), diabetes specialists in own
practices (77.8%), and diabetes specialists in hospitals as well as specialists for diabetic
complication (72.2%) (Fig. B3). Only 9 countries involve all these health professional
categories.
FigB3.Healthprofessionalsinvolvedinthediabetesmanagementprogram
generalpractitioners
94.4
nurses
83.3
diabetesspecialistsinownpractice
77.8
diabetesspecialistsinhospital
72.2
specialistsfordiabeticcomplications
72.2
others
33.3
0
20
40
60
80
100
%
Others: diabetes-consultants (Austria); public health specialists (Croatia); dieticians, patient
associations, healthcare managers (Italy); governmental decision makers, diabetes organization
(Norway); diabetes educators (Spain); pharmacists (Slovenia).
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Themainobjectivesofthemanagementprogramsaretoimprovepatientinvolvementand
the quality of care, and to decrease complications and morbidity (77.8%), followed by
improving early detection of co-morbidities and decreasing mortality (Fig. B4). Reducing
inequalitiesintheaccesstocarewasreportedasoneofthemainobjectiveoftheprogram
byonly9countries.
FigB4.Mainobjectives
improvingpatientinvolvement
77.8
improvingqualityofcare
77.8
decreasing/delayingcomplications
77.8
decreasingmorbidity
77.8
improvingearlydetectionofco-morbidities
72.2
decreasingmortality
66.7
improvingintegrationoforganizations/careproviders
61.1
increasingmulti-disciplinary/professional collaboration
61.1
reducinghospitalizations
61.1
preventing/reducinginappropriatehealthcare
55.6
reducing(public)costs
55.6
reducinginequalitiesinaccesstocare
44.4
other
5.6
0
20
40
60
80
%
Other: develop a follow-up program for persons with type 2 diabetes in the municipalities (Norway).
Key components of the programs are self-management support (72.2%), decision support
tools (66.7%) and delivery system design (61.1%). Clinical information systems are less
presentthantheothercomponents,beingreportedonlyby38.9%oftheresponders(Fig.
B5).
Only the 50% of the diabetes management programs take into consideration vulnerable
groups,e.g.ethnicminoritiesandlowsocio-economicgroups
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FigB5.Keycomponents
100
90
80
70
72.2
66.7
61.1
%
60
50
38.9
40
30
20
10
0
selfdecisionsupport deliverysystem
management
tools
design
support
clinical
information
system
The most important promoter of the management programs is a governmental body
(61.1%), followed by the scientific associations of diabetologists-endocrinologists (44.4%)
(Fig.B6).Onlyonethirdofthediabetesmanagementprogramshavemorethan90%ofthe
personswithdiabetesinvolved,16.7%involved50to70%ofthepersonswithdiabetes,and
16.7% of the programs less than 30%. Half of the participant countries stated that the
programs were implemented in the last 10 years, and about 83% of all the implemented
programsarecurrentlyrunning.OneCountrystoppedtheprogramasplanned,inanother
casethereasonforclosingtheprogramwasaninsufficientmanagementsupport.
FigB6.Promoterofthemanagementprogram
governmentalbody
61.1
diabetologist-endocrinologist/scientificassociations
44.4
primarycareorganization/ scientificassociations
33.3
patientorganization/association
42.1
hospitals
11.8
insurer
11.1
homecareorganization
0.0
other
11.1
0
10
20
30
40
50
%
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70
80
90
100
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Other: public health institutes (Croatia); Steering Committee of National Diabetes Plan (Slovenia).
Most of the programs (72.2%) are monitored through intermediate outcome indicators,
66.7%usedprocessindicatorsandonly44.4%long-termoutcomeindicators(Fig.B7).The
16.7%ofthecountriesdidnotuseanykindofindicator(Annex1-TableB1.16).
FigB7.Indicatorsusedformonitoringthemanagementprogram
100
90
80
72.2
66.7
70
%
60
44.4
50
40
30
20
5.6
10
0
process
indicators
intermediate
outcome
indicators
long-termeffect
indicator
other
Other: implementation indicators (indicators for monitoring the implementation of the program) (Italy).
The diabetes management programs are mostly funded by statutory systems for health
financing(66.7%),andbypublicinsurer(38.9%)(Fig.B8).Halfoftheparticipatingcountries
don’t pay incentives to caregivers, 33.3% adopts a "pay for performance" incentive, and
only11.1%paysincentivesforoutcome.
FigB8.Sourcesoffundingforthemanagementprogram
100
90
80
70
66.7
%
60
50
38.9
40
30
20
11.1
10
5.6
0
statutory
systemfor
health
financing
public
insurers
co-payment
bythe
patient
private
insurers
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0.0
0.0
tradeunions EUstructural
funds
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Almost all the participating countries stated that the basic knowledge of diabetes
managementispartofthecurricula/guidelinesofmedicalprofessionals.Inthe83.3%ofthe
countries the following elements are available: screening protocols/guidelines for early
identification of diabetes, cardiovascular risk assessment tools for persons with diabetes,
assessmentofprognosticfactorprofilesinpersonswithdiabetes(e.g.weight,lipidprofile,
bloodpressureetc.).Definedcarepathwaysexisttodealwithpersonswithdiabetes,either
withoratriskformicro-andmacrovascularcomplications,in77.8%ofthecountries(Fig.
B9).In55.6%oftherespondentcountriesthehealthcareproviderssupportmultidisciplinary
approachesforinterventionsagainstthemetabolicsyndrome.
FigB9.Elementsandtoolsoftheprogram
Curricula/guidelinesofmedicalprofessionals
94.4
Screeningprotocolsforearlyidentificationof
diabetes
83.3
Cardiovascularriskassessmenttoolsavailable
83.3
Prognosticfactorprofileassessedinpersonswith
diabetes
83.3
Definedcarepathways
77.8
Multidisciplinaryapproachagainst themetabolic
syndrome
55.6
0
20
40
60
80
100
%
Data, based on either register or representative samples/cohort of persons with diabetes,
on the proportion of persons with diabetes involved in diabetes management programs,
and complications/co-morbidities of diabetes are publicly available only in the 22-33% of
the programs (Fig. B10). Data on the change of weight and HbA1c level are available at
individual level and included in the individual patient record in about the 90% of the
countries.Changeinbloodpressureandchangeinlipiddisordersareavailableinaboutthe
80% of the countries. The other data (planned visits completed, change in waist
circumference,changeinthepresenceofthemetabolicsyndrome)areavailableinthe3961%oftheprograms(Fig.B11).
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FigB10.Availabledata/statisticsatpopulationlevel
100
Public
90
Onrequest
80
70
55.6
%
60
55.6
55.6
55.6
55.6
50.0
50
44.4
44.4
44.4
38.9
40
33.3
30
22.2
22.2
22.2
22.2
22.2
22.2
22.2
16.7
20
11.1
10
0
diabetics diabeticfoot lowerlimb diabetic
diabetic myocardial
involvedin syndrome amputations retinopathy nephropathy infarction
DMPs
stroke
hypertension
lipid
disorders
metabolic
syndrome
FigB11.Availabledataatindividuallevel
100
90
88.9
80
88.9
83.3
77.8
70
61.1
%
60
55.6
50
38.9
40
30
20
10
0
weightchange
changein
changein changeinlipid plannedvisits changeinwaist
HbA1clevel bloodpressure disorders
completed circumference
changein
metabolic
syndrome
status
In summary almost all the countries, 18 out of the 19 respondents, have a management
program for diabetes. Nevertheless only one third of the programs were characterized by
thefollowingelements:
•
•
•
•
•
vulnerablegroupsconsidered
at least one of 4 key components defined (self-management support, delivery system
design,decisionsupporttool,clinicalinformationsystem)
screeningprotocol/guidelinesforearlyidentificationofdiabetesavailable
data on comorbidities/complications (e.g. diabetic foot syndrome, lower limb
amputations,diabeticrethinopaty,diabeticnephropaty,…)available
definedcarepathwaysforpersonswithdiabetes,eitherwithoratriskformicro-and
macrovascularcomplications.
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C-EDUCATIONPROGRAMSFORPERSONSWITHDIABETESANDTRAININGFOR
PROFESSIONALS
Educationforpersonswithdiabetesisconsideredanintegralcomponentofdiabetescare,
andit'sintendedmainlytodevelopskillsinself-managementandcontributetothepatient
empowerment. Effective education provision needs trained health professionals, with
expertiseineducationanddiabetesmanagement.
Inthecontextofpatienteducation,aneducationprogramisaninternationalacceptedand
vital intervention with a targeted structure of education for people with diabetes with an
evident effect on the therapy and prognosis of diabetes. Usually, it means that the core
contents,goals,methodsanddidacticsaredescribedinacurriculumandmaterialsortools
for the educators and participants are provided. Education for persons with diabetes is
described as a complex intervention with special requirements on evidence and
transparency regarding its rationale, methodology, performance and outcome
representation.
Healthprofessionalsneedtobetrainedtobecomeeffectiveeducators,andthisentailsthat
training programs and curricula are necessary to prepare people for the role of diabetes
educator.Diabeteseducationisaspecialtyandrequiresknowledgeandcompetenceatan
advancedlevelifitistobedeliveredeffectively.
Effectivecurricula,forbotheducatorsandpeoplewithdiabetes,shouldhaveinstructional
strategies and approaches based on theories of learning, for example behaviourism,
constructivism, social constructivism, that go beyond the cognitive level and addresses
health determinants, social factors, attitudes, values, norms, and skills that influence
specifichealth-relatedbehaviours.
Educationprogramsforpersonswithdiabetes
On the whole, 15 out of the 19 participating countries reported education programs for
personswithdiabetes.Onlyafewcountriesstatedtohaveaneducationprogramthatexists
in a stand-alone national program (15.8%), while 36.8% reported to have education
programs that are included in a more comprehensive National plan. Slightly more than a
half(57.9)oftheparticipatingcountriesreportedtohaveeducationprogramsavailableat
sub-nationalorlocallevelthatcovereducationactivitiesforpersonswithdiabetes(Fig.C1).
Cyprushasastand-alonenationalprogramincludedinamorecomprehensivenationalplan.
In Greece, the education of persons with diabetes depends on the diabetic clinics, the
diabetesspecialistsortheGPsresponsiblefordiabetesmanagementandcare.Indiabetes
clinics there are educational programs in which nurses, psychologists and dieticians are
involved,butnotaspecificprogramorleadingorganizationcanbedescribed.
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FigC1.Percentageofcountrieswithaprogramthatcoverseducationactivitiesforpersons
withdiabetes
100
80
57.9
%
60
36.8
40
20
15.8
0
existsinstand-alone
nationalprogram
includedinamore
comprehensiveNP
existsatsubnational/locallevel
Note.The sum of the percentage is not 100% because the options are not mutually exclusive.
Fourcountriesdidnothaveordidnotdescribeeducationprograms(Annex1-TableC1),the
analyses in the following section are relative to the 15 respondent countries. In Belgium
educationisprovidedatthepointofdiagnosisandthereafter.Therearedifferenteducation
programs based on international guidelines depending on the region and sub-region of
Belgium. The education topics health promotion, self-management education, diabetes
knowledge, prevention of diabetes complications were reported to be considered in
education programs in almost all the participating countries (Fig. C2). About 67% of the
counties reported that the change in HbA1c level is a topic in education programs. Stress
management (46.7%) and other situations (26.7%), e.g. pregnancy, illness, extensive
physicalactivity,arelessreportedtopics.
FigC2.Topicsincludedintheeducationprogram
100
90
70
%
50
100.0
93.3
100.0
100.0
80
66.7
60
46.7
40
26.7
30
20
10
0
healthpromotion self-management
interventions
education
diabetes
knowledge
preventionof
diabetes
complications
managementof changeinHbA1c
stress
level
other
Other:healthliteracy(France);improvedself-efficacyandqualityoflife,amelioredempowermentin
people with diabetes (Italy); special situations (pregnancy, illness, extensive physical activity)
(Romania); functional insulin therapy, diabetes in pregnancy, newly diagnosed type 2 diabetes
initiationofinsulintherapyintype2diabetes(caregiversfrequentlyinvolved)(Slovenia).
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An important issue in education activities is the definition of the specific population to
which the activity is targeted. Most countries (86.7%) report that programs address all
peoplewithdiabetes(Fig.C3).Morethanahalfofthecountriesreportprogramsaddressing
peoplewithnewlydiagnoseddiabetesorpeoplewithdiabetesandco-morbidities.
Apercentagerankingfrom60.0to86.7%oftheparticipatingcountriesstatedthatthegoal,
the rationale, the target group, the setting, the scheduling of the education sessions, the
core components of the educator/trainer role, the qualification of the trainers/educators,
and the number of participants are defined in education programs (Fig. C4). About a half
stated that environmental requirements, monitoring of effectiveness and quality, and a
sourceoffundingisdefinedineducationprograms.
FigC3.Targetgroup
%
100
90
80
70
60
50
40
30
20
10
0
86.7
66.7
60.0
40.0
26.7
allthepersonswith
personswith
personswithanew
diabetes
diabeteswithcodiagnosisof
morbidities
diabetes
relatives,
caregivers
other
Other: All persons with diabetes enrolled in DMP Therapie Aktiv (Austria). Persons with health
insurance, 18 years or older with pharmaceutical therapy and identified GP (France). The target
groups are different in different locations (Romania). Pregnant women, newly diagnosed type 2
diabeteswithinsulintherapy(caregiversfrequentlyinvolved)(Slovenia).
FigC4.Definedcriteria
goals
rationale
setting
66.7
66.7
numberofparticipants
73.3
schedulingoftheeducationsessions
corecomponentsoftheeducator/trainer'srole
86.7
targetgroup
86.7
66.7
60.0
qualificationofthetrainers/educators
60.0
environmentalrequirements
53.3
monitoringeffectivenessandquality
53.3
sourceoffunding
53.3
0
10
20
30
40
50
%
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60
70
80
90
100
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About 70% of respondents reported to have a defined specific education methods and
didactics,andanevidencebasedcurriculum,60%reportedthatthecurriculumisevaluated
and still less (46.7%) reported that the education program is based on a theory driven
curriculum(Fig.C5).
FigC5.Topicsincluded
100
90
80
70
60
50
40
30
20
10
0
60.0
66.7
46.7
theorydriven evaluated
curriculum curriculum
73.3
66.7
evidence
based
curriculum
specific
education
methods
specific
education
didactics
Morethanahalfoftheeducationprograms(60%)wereimplementedaftertheyear2000,
and all the implemented programs are reported as currently running. In France, the time
frame, 4 years, is given for each program following the licensing process at the regional
level.
Theimplementationleveloftheeducationprograms(Fig.C6)ismostfrequentlyreported
on regional and local level (60% each), than on national level (40%). All the respondents
reportededucationprogramsspreadonurbanlevelandthe93.3%alsoonrurallevel.
FigC6.Implementationlevelandspread
%
100
90
80
70
60
50
40
30
20
10
0
93.3
60.0
100.0
60.0
40.0
local
regional
national
rural
ImplementationlevelSpread
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The strongest promotor (Fig. C7) seems to be scientific associations of diabetologistsendocrinologists (60%), followed by governmental body and patient
organizations/associations(40%).
FigC7.Promoteroftheprogram
60.0
diabetologist-endocrinologist/scientificassociations
governmentalbody
40.0
patientorganization/association
40.0
hospitals
33.3
primarycareorganization/ scientificassociations
33.3
insurer
13.3
homecareorganization
0
other
26.7
0
10 20 30 40 50 60 70 80 90 100
%
Other: Dieticians (Ireland). Multidisciplinary team with pedagogists and diabetologists (Italy).
AndalusianSchoolofPublicHealth(Spain).Registerednurses,educatorsfordiabetes(Slovenia).
Indicatorsusedformonitoringareonstructure,processandoutcomelevel.However,only
20%oftheparticipatingorganizationsreportedthatlong-termeffectindicatorsareapplied
tomeasureeducationprograms(Fig.C8).It’stonoticethatsomecountriesdon’tadoptany
kindofindicator(Annex1-TableC1.15).
%
FigC8.Indicatorsusedformonitoring
100
90
80
70
60
50
40
30
20
10
0
53.3
53.3
46.7
20.0
structure
indicators
process
indicators
intermediate long-termeffect
outcome
indicator
indicators
Note: Within the program evaluation of the DMP Therapie Aktiv a number of indicators were taken
into account, however most indicators are not related to the education program (Austria). The
education programme was monitored with continuous evaluation of the clinical and psychological
indicator (Italy). Not monitored everywhere or all the time (UK).
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Sourcesoffundingfortheeducationprogramseemtobebasedonastatutorysystemfor
healthfinancing,in60%ofthecases,andonpublicinsurersin33.3%ofthecases(Fig.C9).
Other sources are mixed, e.g., statutory system for health financing, public or private
insurersand/orprivateorganizations.InRomania,astheprofessionoftherapeuticeducator
isnotofficiallyrecognized,theeducationprogramsaredeliveredindifferentlocationswith
different consistencies and frequency. There is no system of follow up or monitoring the
impact of the education programmes. Different clinics use different curricula for these
programmes,andthereisnoofficialfundingforsuchactivities.
FigC9.Sourcesoffundingfortheeducationprograms
%
100
90
80
70
60.0
60
46.7
50
40
33.3
30
20
6.7
6.7
6.7
10
0.0
0
statutory
public
private
co-payment tradeunions EUstructural
other
systemfor
insurers
insurers bythepatient
funds
health
financing
Other:Regionaldifferencesexist,e.g.theprogramisco-fundedbypublicinsurersandtheregional
government (Austria). No financing scheme at the national level (France). Unrestricted grant from
pharmacompany(Portugal).Thepatienteducationprogrammesarenotfunded(Romania).Health
Service Executive Ireland (Ireland). Research funding by private organization (EFSD, Compagnia di
SanPaolo)(Italy).Localhealthcareorganizationsandorpharmaceuticalcompanies(UK).
Insummary,educationprogramsexistin8outof10oftheparticipatingcountries.Thecore
criteria of the quality of education programs are defined, e.g. the goal, the rationale, the
target group, the setting, the scheduling of the education sessions. More than a half
reportedtohaveanevidence-basedcurriculumanddefinedspecificeducationmethodsand
didactics.
However,therearesomediscussionpoints.Although,themanyqualitycriteriaaredefined
ineducationprograms,onlythe60%reportedthatthecurriculumisevaluated,andalow
number of the participating organizations (20%) reported that long-term effect indicators
were used. Additionally, the participating countries described which target group is
addressedineducationprograms,e.g.peoplewithdiabeteswithorwithoutcomorbidities,
butonly73%reportedthatthetargetgroupisdefinedintheeducationprogram.
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Trainingprogramsforprofessionals
Outofthe19participatingcountries,only13reportedtohaveprogramsfordiabetesthat
covers health professional training. About half of the participating countries (47.4%)
reportedtohavetrainingprogramsavailableatsubnationalorlocallevelthatcovertraining
activitiesforhealthprofessionals(Fig.C10).About20%reportedtohavetrainingprograms
that exist in a stand-alone national program, and in the 10% the program is included in a
morecomprehensiveNationalPlan.
FigC10.PercentageofCountrieswithaprogramfordiabetesthatcovershealth
professionaltraining
%
100
90
80
70
60
50
40
30
20
10
0
47.4
21.1
10.5
existsinstand-alone
nationalprogram
includedinamore
comprehensiveNP
existsatsubnational/locallevel
Sixcountriesdidnothaveordidnotdescribeanytrainingprogram(Annex1-TableC2)and
wereexcludedfromtheanalysesreportedinthissection.
Themajorityofthedescribedtrainingprogramsdefinethegoal,thetargetgroupandthe
scheduling of the training sessions (Fig. C11). About 70% reported that the training
programs define the setting, the number of participants, the qualification of the
trainers/educators and the core components of their role. Only a few stated that a
monitoringofeffectivenessandqualityisdefined(38.5%).
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FigC11.Definedcriteriaforthetrainingprogram
goals
84.6
targetgroup
76.9
schedulingofthetrainingsessions
76.9
setting
69.2
numberofparticipants
69.2
qualificationofthetrainers/educators
69.2
corecomponentsoftheeducator/trainer'srole
69.2
rationale
61.5
sourceoffunding
61.5
environmentalrequirements
53.8
monitoringeffectivenessandquality
38.5
0
10
20
30
40
50
60
70
80
90
100
%
Theprogramscontainspecifictrainingmethodsforthe76.9%ofthecases,andthe61.5%
reported that the programs are based on an evidence based curriculum; only the half
reportedthatthecurriculumisevaluatedandevenlessreportedthatthetrainingprogram
isbasedonatheorydrivencurriculum(Fig.C12).
FigC12.Topicsincluded
100
90
80
70
60
50
40
30
20
10
0
76.9
53.8
61.5
69.2
46.2
evaluated theorydriven
curriculum curriculum
evidence
based
curriculum
specific
training
methods
specific
training
didactics
Most of the training programs (75%) were implemented after the year 2005, and all are
currently running. The implementation level of the training programs (Fig. C13) is most
frequentlyreportedonlocallevel(61.5%),lessonregionalornationallevel(46.2%).Allthe
respondentsreportedtrainingprogramsspreadonurbanlevelandthe84.6%alsoonrural
level.
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FigC13.Implementationlevelandspread
100
90
80
70
60
50
40
30
20
10
0
100.0
84.6
61.5
%
local
46.2
46.2
regional
national
rural
urban
ImplementationlevelSpread
Theprogramsaremorefrequentlypromotedbythescientificassociationsofdiabetologistsendocrinologistsandbygovernmentalbody(38,5%)(Fig.C14).
FigC14.Promoteroftheprogram
governmentalbody
38.5
diabetologist-endocrinologist/scientificassociations
38.5
primarycareorganization/ scientificassociations
23.1
patientorganization/association
15.4
hospitals
7.7
homecareorganization
7.7
insurer
7.7
other
30.8
0
10
20
30
40
50
60
70
80
90
100
%
Other: Diabetes nurses and diabetologists in cooperation with the university (Austria); academic
institutions (Romania); Universities for Applied Sciences (Finland); Academic organisations (UK).
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Indicatorsusedformonitoringareonstructureandprocesslevel(61.5%).Only30.8%ofthe
participating organizations reported that intermediate outcome indicators are applied to
measuretrainingprograms(Fig.C15),andsomecountriesdonotuseanykindofindicator
(Annex1-TableC2.15).
FigC15.Indicatorsusedformonitoring
100
90
80
70
61.5
61.5
60
%
50
40
30.8
30
20
10
0
structureindicators
processindicators
intermediateoutcome
indicators
Sourcesoffundingforthetrainingprogramsseemtobebasedmainlyonastatutorysystem
forhealthfinancing(53.8%)andonpublicinsurers(Fig.C16).Othersourcesaremixed,e.g.,
private funding (students), hospitals, pharmaceutical companies. All the respondent
countriesstatedtheydonotuseincentivepayment,exceptonecountrythatusepayment
forperformance(Annex1-TableC2.31).
FigC16.Sourcesoffundingforthetrainingprogram
100
90
80
70
%
60
53.8
50
40
30
23.1
15.4
20
10
0.0
0
statutory
systemfor
health
financing
public
insurers
private
insurers
7.7
co-payment
bythe
patient
0.0
0.0
trade
unions
EU
structural
funds
other
Other: private fundings (students), hospitals, pharmaceutical companies (Austria); educational
system (Finland); co-payment by the professionals (Portugal).
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In summary, training programs for professionals exist in more than two/third of the
participating countries. The core criteria of the quality of training programs seem to be
defined, e.g., the goal, the rationale, the target group, the setting, the scheduling of the
training sessions. More than a half reported to have an evidence-based curriculum and
definedspecifictrainingmethodsanddidactics.
However,therearesomediscussionpoints.Although,themanyqualitycriteriaaredefined
intrainingprograms,onlyalownumberoftheparticipatingorganizationsreportedthata
monitoringofeffectivenessandqualityofthetrainingprogramisdefined.Lessthanahalf
reported that the training program is based on a theory driven curriculum and only the
30.8% reported that intermediate outcome indicators are applied to measure training
programs.
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