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Background and Aims: Transferring the results from clinical trials on type 2 diabetes prevention is the objective of the Diabetes in Europe-Prevention using Lifestyle, Physical Activity and Nutritional intervention (DE-PLAN) project in Catalonia, whose cost-effectiveness analysis is now presented., Patients and Methods: A prospective cohort study was performed in primary care involving individuals without diagnosed diabetes aged 45-75 years (n=2054) screened using the questionnaire Finnish Diabetes Risk Score (FINDRISC) and a subsequent oral glucose tolerance test. Where feasible, high-risk individuals who were identified (n=552) were allocated sequentially to standard care (n=219), a group-based (n=230) or an individual-level (n=103) intensive (structured programme of six hours using specific teaching techniques) lifestyle intervention (n=333). The primary outcome was the development of diabetes (WHO). We evaluated the cost of resources used with comparison of standard care and the intervention groups in terms of effectiveness and quality of life (15D questionnaire)., Results: After 4.2-year median follow-up, the cumulative incidences were 18.3% (14.3-22.9%) in the intensive intervention group and 28.8% (22.9-35.3%) in the standard care group (36.5% relative-risk-reduction). The corresponding 4-year HR was 0.64 (0.47-0.87; P<.004). The incremental cost induced by intensive intervention compared with the standard was 106€ per participant in the individual level and 10€ in the group-based intervention representing 746€ and 108€ per averted case of diabetes, respectively. The estimated incremental cost-utility ratio was 3243€ per quality-adjusted life-years gained., Conclusion: The intensive lifestyle intervention delayed the development of diabetes and was efficient in economic analysis., (Copyright © 2013 Elsevier España, S.L. All rights reserved.)

Background and Objective: To assess the relevance of unrecognised hyperglycaemia among high-risk subjects for developing type 2 diabetes., Subjects and Method: Cross-sectional multicentre study in primary care. Subjects aged 40 to 75 years with previous evidence of impaired glucose metabolism were screened according to the World Health Organization rules by means of an oral glucose tolerance test (OGTT). Those with diabetes diagnostic criteria were excluded. An individualized 48-h ambulatory continuous glucose monitoring (CGM) calibrated by plasma values (Glucoday) was performed. Data from biosensor activity were computerized in order to identify hyperglycaemic records., Results: 50 out of 64 screened subjects were included and evaluated; there were 30 female (60%). Mean age was 59 years; body mass index, 30.9; HbA1c, 5.3%, and HOMA, 2.8. Regarding the CGM results, 9 whole registers (18%) were rejected because of technical problems and 41 continuous profiles (72%) were analysed, corresponding to 17 (41.5%) subjects with normal OGTT and 24 (58.5%) with non-diabetic hyperglycaemia on OGTT. Mean CGM time with hyperglycaemia (fasting > or = 6.1 mmol/l or non-fasting > or = 7.8 mmol/l) accounted for 5.8 h, a 17.2% of the effective register per subject (33.8 h). Both groups matched the World Health Organization diabetes diagnostic interval (fasting > or = 7 mmol/l or non-fasting > or = 11.1 mmol/l): 1.1 h of effective register (3.6%) and 1.2 h (3.3%), respectively., Conclusions: The CGM evidenced a high degree of unrecognised hyperglycaemia among high-risk individuals. Therefore, casual plasma glucose measurements should be recommended to achieve early screening.

Objective: To estimate stroke risk for diabetes, isolated or associated to metabolic syndrome (MS) according WHO and National Cholesterol Education Program (NCEP) criteria., Design: Multicentre and prospective cohort study., Setting: Primary health care., Participants: Subjects between 55-85 years-old without any evidence of stroke, included from 1998 in a random population sample for MS follow-up during routine practice in Reus (Tarragona, Spain)., Main Measurements: Stroke risk was achieved using Framingham function by means of a computerized algorithm using a diagnostic factorial design (diabetes and/or MS). Theoretical stroke risk and cumulated incidence of stroke events (1998-2003) were compared., Results: Among 728 subjects (412 women, mean age =66 years old, body mass index =29 kg/m2), 457 (62.8%) did not have diabetes, nor MS, 93 (12.8%) had MS without diabetes, 72 (9.9%) diabetes without MS, and 106 (14.5%) presented both conditions (WHO rules). According NCEP criteria were 60.7%, 14.8%, 7.8%, and 16.7%, respectively. Ten-year estimated stroke risk accounted for (WHO/NCEP) 8.4/9.1%, 10.8/10.5%, 18/17.3%, and 18.8/19.1%. Cumulated incidence for stroke events were: 2.8%, 1.4%, 5.4%, and 3.8% (WHO), and 2.5%, 2.8%, 3.5%, and 5.8%, respectively (NCEP)., Conclusions: Stroke risk scores were extremely increased among diabetic subjects irrespective to MS diagnose. The Framingham function probably overestimates stroke risk among Spanish individuals.

Objective: To evaluate the accuracy of continuous blood glucose monitoring (CBGM) in order to asses diagnostic procedures and predict glycaemic status in type 2 prediabetes., Design: Observational, multicenter, cross-sectional (phase 1) plus longitudinal, cohort follow-up study (phase 2)., Setting: Five primary health-care centers., Interventions: A total of 84 high-risk subjects will be included after a non-diabetic oral glucose tolerance test (OGTT). A first CBGM using a subcutaneous microdialysis glucose sensor technique in order to obtain a continuous profile will be carried out. Two different cohorts, subjects with normal OGTT (n = 42) and individuals with prediabetic hyperglycemia (n = 42) will be established. Diagnoses will be revised at 12 and 24 month follow-up by means of an OGTT together with a new monitoring., Main Measurement: Demographical, clinical (including metabolic syndrome items), basic, and advanced analyses (inflammation emergent markers, insulinemia, C-peptide). CBGM computerized analysis comparing fasting, preprandial, postprandial, nocturnal period, and area under the curve of continuous profile with regular diagnoses, taking into account temporary concordance. Relationship of CBGM parameters with normal glucose tolerance or diabetes incidence. Evaluation of day-to-day quality of life of CBGM users by means of an standardized Likert questionnaire., Discussion: This study seeks to demonstrate the effectiveness and feasibility of CBGM, more physiological than OGTT and based on an underestimated random blood glucose diagnostic criterion. This innovative system may provide interesting scientific data in the field of type 2 prediabetes.

Unlabelled: AIM. To identify the differences between coronary heart disease risk in patients with altered basal glucemia (ABG), oral glucose intolerance (OGI) and type II diabetes mellitus according to the WHO-85 and ADA-97 diagnostic classifications, in an adult population at high risk for diabetes mellitus., Design: Descriptive, cross-sectional, multicenter study.Setting. Seven primary health care centers in Spain.Patient. 970 persons considered the population at risk for type II diabetes mellitus., Measures: Participants were classified according to the criteria of the WHO-85 (normal, OGI, diabetes) and the ADA-97 system (normal, ABG, diabetes). The following variables were recorded: age, sex, smoking habit, body mass index, systolic blood pressure, diastolic blood pressure, basal glucemia, glucemia 2 h after an oral glucose tolerance test, HbA1c, microalbmuniuria, total cholesterol, HDL, LDL and triglycerides. Coronary heart disease risk was calculated with the 1998 table developed by Wilson et al. on the basis of the Framingham study., Results: A total of 970 participants were studied. Mean age was 58.6 #+ 12.4 years; 453 were men (46.7%) and 517 were women (53.3%). Our analysis showed that cardiovascular disease risk factors were less frequent in normal subjects, and that their prevalence was higher in persons with diabetes (according to both WHO and ADA classifications). There were no significant differences in coronary heart disease risk or different risk factors between analogous groups in the two classification systems (normal, OGI/ABG or diabetes). Coronary heart disease risk in persons with different types of alterations in glucose metabolism was 11.3% in normal subjects, 14% in persons with OGI and 27.3% in persons with diabetes according to the WHO-85 system, and 11.4% in normal subjects, 15.7% in persons with ABG and 29.5% in persons with diabetes according to the ADA-97 system., Conclusions: The greater the alteration in carbohydrate metabolism, the greater the coexistence of risk factors and the estimated risk of coronary heart disease. There were no significant differences in the presence of cardiovascular risk factors, or in the relationship between carbohydrate metabolism and coronary heart disease risk, between analogous stages identified with one classification system or the other.

Background: Our purpose was to estimate the incidence of type 2 diabetes among a high risk population with or without impaired glucose tolerance (IGT), analysing the progression to diabetes., Patients and Method: Multicenter cohort study on high risk individuals without diabetes (WHO-85 criteria) in primary health care. Subjects underwent an oral glucose tolerance test measuring fasting plasma glucose (FPG) and plasma glucose at 2 hours (2hPG). Mean follow-up was 37.2 months (4.3-69.7). Phenotypic features, diagnostic variation, diabetes incidence and predictive factors (multivariate analysis and Cox proportional hazards model) were assessed., Results: We included 243 individuals (148 females), aged 59.7 (10) years, with FPG < 7.8 mM and 2hPG < 11.1 mM. 137 IGT subjects (56.4%) and 106 (43.6%) normal glucose tolerance (NGT) subjects with a similar risk factor impact were evaluated. After the study was closed, 63 (25.9%) subjects developed diabetes: 43 (31.4%) with baseline IGT and 20 (18.9%) with NGT. Overall diabetes incidence increased over time but not proportionally. Mean annual incidence was 9.2% and it dropped to 4.6% when FPG was used as the unique diagnosis criterion (ADA-97). Male under 65 years with both overweight and IGT reported the highest incidence. HbA1c, FPG and 2hPG were independent predictors. Increased HDL cholesterol showed a protective effect on diabetes incidence. The IGT diagnosis interval was a much better predictor [OR = 2.06 (1.56-2.72)] of diabetes development than the impaired FPG diagnosis interval [OR = 1.37 (0.93-2.04)]., Conclusions: FPG predicted but undervalued diabetes incidence in high risk population. The IGT (2hPG) diagnosis interval predicted diabetes development better than the impaired fasting plasma glucose diagnosis interval. Increased diabetes incidence in high risk Spanish population, particularly with regard to IGT, means that primary preventive resources should be increased.

Background: To estimate the prevalence of undiagnosed diabetes and impaired glucose metabolism on high risk Spanish population, contrasting phenotypic features according to both sets of criteria, World Health Organization (WHO) and American Diabetes Association (ADA)., Subjects and Methods: Cross-sectional, multicentre (10 health-care centres, 230,000 inhabitants), selective risk-factor study. WHO diagnoses (normal, impaired glucose tolerance [IGT] and diabetes) were based on the 2 h plasma glucose (2hPG) following a 75 g oral glucose tolerance test (OGTT) and ADA diagnoses according the fasting plasma glucose (FPG) (normal, impaired FPG and diabetes). Prevalence, diagnostic overlap index and 22 clinical and biological parameters were compared., Results: The study included 580 subjects (330 women), mean age 58.1 years and body mass index 31.2 kg/m2, 292 (50.3%) with only one risk factor and 288 (49.7%) with two or more risk factors. WHO diagnoses were: 291 (50.2%) normal glucose tolerance (95% CI: 46.2-54.2%), 157 (27.1%) IGT (23.5-30.7%) and 132 (22.7%) diabetes (19.3-26.1%). ADA diagnoses were: 355 (61.2%) normal FPG (57.2-65.2%), 146 (25.2%) IFG (21.7-28.7%) and 79 (13.6%) diabetes (10.9-16.3%). The prevalence of diabetes decreased 9.1% (from -11.4 to -6.8%). The diagnostic overlap was 33.5% for diabetes and 19.3% for impaired glucose homeostasis (IGT-FPG). Omitting the OGTT half the diabetic subjects with 2hPG > or = 200 mg/dl (11.1 mM) but FPG < 126 mg/dl (7 mM) would remain undiagnosed. By changing screening criteria (FPG instead of 2hPG) the risk related to traditional factors such as age or a first-degree relative with diabetes would reduce., Conclusions: Applying ADA criteria, the high prevalence of undiagnosed glucose abnormalities would decrease. These results suggest that it is strongly advisable the continued use of the 2hPG for diabetes screening on high risk Spanish population.

Background: To compare the cost and effectiveness of bedtime intermediate-acting insulin and daytime-sulfonylurea (SU) combination therapy versus the conventional two-daily-dose insulin treatment., Subjects, Material and Methods: A pharmacoeconomical analysis of cost minimization. To prove a similar effectiveness a transversal prospective study was carried out. Patients recently converted to insulin due to oral hypoglycaemic agents failure were recruited. Entry criteria were: age > 40 years-old, more than 3 and 1 years of diagnosed diabetes and follow-up, respectively, current BMI between 20-40 kg/m2, baseline HbA1c > 8.5% and fasting C-peptide > 0.3 nmol/l. BMI, HbA1c, hypoglycaemic crisis, insulin and SU (glicazide and glibenclamide) daily dose were recorded, estimating the cost of both therapies., Results: Sixty-five patients (23 male), 32 in combined therapy (mean daily dose of insulin 19.5 U and 2.4 SU tb t.i.d.) and 33 patients with a two-insulin-injection regimen (38.4 U) were treated during a follow-up period of 2.4 years. The two groups exhibited similar mean age (67.8/67.7y), known diabetes duration (15.9/15.1y), BMI (28.9/28.8/kg/m2), previous HbA1c (8.9/9.1%) and fasting C-peptide (1.6/1.2 nmol/l). No statistical differences in BMI increase (1/1.4 kg/m2), neither in mean HbA1c (7.8/7.9%) nor severe hypoglycaemic crisis (0.03/0.17 episodes/year) were evidenced. Patients in combined therapy reported a lower number of mild hypoglycaemic crisis (0.7/1.9 episodes/month; p < 0.01) and the daily cost was significantly lower (94.5/134.3 ptas./day; p < 0.0001)., Conclusions: Both therapies, two-insulin-injection regimen and insulin and sulfonylurea combination therapy were similarly effective in having an acceptable glycaemic control with similar risk for weight gain or severe hypoglycaemia. Combined therapy was more cost-effective and well-tolerated, thus, comfort and a lower risk of mild hypoglycaemic episodes were evidenced.

Objective: To investigate the number of people with intolerance to glucose (ITG) and undiagnosed diabetes (DM) among primary care users at risk., Design: Prospective, selective urban polling of a representative sample of those attended in the city of Reus (88,000 inhabitants)., Setting: Two base health areas (10 Primary Care teams) with an approximate overall reference population of 45,000 inhabitants., Patients and Other Participants: Clinical and examination data were recorded with a pre-designed questionnaire. Diagnoses were established by means of base glycaemia (mmol.l-1 or a 75 g glucose oral overload (0 and 120 minutes) for users over 40 with some Diabetes risk factor. Further tests were HbA1C (%), base peptide-C (nmol.l-1, total cholesterol, HDL cholesterol, triglycerides (mmol.l-1 and 24-hour microalbuminuria (mg)., Measurements and Main Results: After a year included in the survey, the data of 345 people were evaluated: 151 men, 58 years old (95% CI, 57-60) and BMI of 30.8 (30.3-31.4), with 197 diagnoses (57.1%) of normal tolerance to glucose (52-62%). 82 (23.8%) of ITG (20-28%) and 66 (19.1%) of undiagnosed DM (15-23%). Significant differences between the three were detected in age (56/61.5/61.7 years, p < 0.001), proportion of men (38/50/53%, p < 0.05), diagnosis of hypertension (40.6/59.8/53%, p < 0.01), previous anomaly in tolerance 28.4/45.1/51.5%; p < 0.001), HbA1C (4.6/4.9/5.4; p < 0.001), systolic pressure (140.5/143.6/151 mmHg, p < 0.007). Triglycerides (1.4/1.6/2.1, p < 0.001) and microalbuminuria (16/29/51, p < 0.001). Base peptide-C (3.5/3.8/3.8) showed no statistical differences., Conclusions: Selective detection in primary care amply exceeds opportunist detection in identifying patients with ITG who might be susceptible to preventive measures. In function of the intolerance level, from normality through to DM, statistical differences were found in HbA1C, systolic pressure, Triglyceridaemia and urinary excretion of albumin. These were not extendable to the rest of the lipid profile or to endogenous insulinaemia.

Background: The U100 insulin (100 units [U]/ml) in only used in a minority of Spanish hospitals and is not ordinarily evaluated. To study the convenience of converting from U40 (40 U/ml) to U100 insulin in a first level hospital, the procedure, costs and professional acceptance were analyzed after one year of experience., Subjects and Methods: The chronology and the transfer method are described making an interannual pharmacoeconomical comparison of costs U40/U100 based on insulin intake and injection material. The primary source of information was the computerized base of admission, pharmacy and supply. The secondary source included the obligatory registries of daily medicine sheets. Nursing staff acceptance of the new system (preloaded U100 syringes) was analyzed with a predesigned quantitative scale questionnaire., Results: In the U40 phase, 69,600 U and 8,260 syringes were used to satisfy 136 diabetics at a mean prescription of 21 U/day for 10.9 days. In the U100 phase, 92,100 U and 1,682 syringes were used for 132 admissions with a mean dose of 20 U during 8.6 days. The insulin prescribed and injected was 45.5% and 24.7%, respectively with the consumption of non injected insulin in the center being 20.8%. On taking only the fraction injected into consideration, the mean daily cost per complete treatment was lower in U100 (116/84 and 1,368/809 pesetas; p < 0.0001) representing 0.53% (U40) and 0.36% (U100) of hospital stay costs. The total cost increased by 44 ptas./patient/day during the first year of conversion. Each section of the 67 questionnaires evaluated scored from 4 (greatest acceptance) to 20 (lowest acceptance). The general mean was 6.8 +/- 1.6 with no significant differences between the section of management/manipulation of U100 devices (6.7 +/- 2.1), learning and protocol (7.3 +/- 2.6) and patient education (6.5 +/- 1.8; p = 0.07, NS)., Conclusions: Current hospital conversion to U100 insulin requires the use of mechanized injection systems which represent a slight extra cost of scarce social relevance and are greatly accepted by users if adequate transfer procedures are applied.

Objective: To investigate the level of attendance for care of people with glucose tolerance disorders, both known and not, and to discuss their real impact on Primary Care., Design: Simple prospective randomised sampling. Opportunist detection among spontaneous users over 40, excluding pregnant women., Setting: Primary Health Care., Patients and Other Participants: Data was recorded using a pre-designed survey, which included the recognised Diabetes (DM) risk factors., Measurements and Main Results: Of the 183 cases evaluated, DM was already known in 13 (7.1%). 15 (8.2%) with unknown DM and 27 (14.7%) with GIT. A strong link was demonstrated with the average age and a marked tendency to overweight and obesity only significant when comparing DM with the rest. As to the risk factors researched, there was a significant association with antecedents of prior tolerance abnormality, DM in pregnancy, hyperglucaemiant medicines and ischaemic disease, in cases where family antecedents of definite diabetes were not found., Conclusions: The frequency of attendance of users with diabetes and unknown glucose tolerance disorders is very high in spontaneous primary care consultations. These results suggest that opportunist detection should be encouraged in primary health care centres.

Objectives: In Spain today there are three ways of injecting insulin, the traditional syringe (TS) and two automatic methods: injector pens (IP) and preloaded syringes (PS). The main aim of the study was to compare their efficiency in normal use; and the second, to compare their effectiveness in terms of how they suited the clinical profile and needs of the users., Design: A pharmacoeconomical study to minimise costs., Setting: Two Primary Care clinics, one specialising in diabetes and the other not, and a third clinic, part of hospital out-patients., Patients and Other Participants: Systematic examination of the insulin packages and the material used by 108 diabetics (3 groups of 36, divided by the method of injection) over an average period of 51 days., Measurements and Main Results: The average dose prescribed was 34.7 units (U) per day, supplied in 2.2 injections per day. The real average dose consumed was 41.4 U per day with an average daily loss of 3.1 U per injection and average re-use of needles at 7.1 times per patient. Type 11 diabetics, older patients and those with worse eye sight used TS more often. Younger and Type 1 diabetics and those who needed more injections generally used an automatic method, in particular IP. PS seemed to be used by both types of diabetic indifferently. There were significant differences found between users of TS, IP and PS regarding the doses taken (44.6, 45.1 and 34.5 U; p < 0.03), the daily loss per injection (4.5, 3.2 and 1.4 U; (p < 0.0004) and in the re-use of needles (4.1, 7.7 and 8.1 times; p < 0.02)., Conclusion: If we suppose similar efficacy, automatic systems are more efficient in reality than traditional syringes and insulin vials.

Background: A study was performed to analyze the use of reactive material in the periodic follow up of diabetes. Likewise, the use of systems to assess glycemic control by primary care physicians was investigated., Methods: Analysis of the habits of use of reactive material was performed on the diabetic population of Tarragona (548,900 inhabitants) by randomized survey of prescription in 525 patients attended in 12 primary care centers. The estimation of amount was carried out by a counting of the public prescriptions made. Similarly the periodicity and the results of the applications of glucoproteins in the reference laboratories were studied., Results: A total of 253 diabetics (48%) were exclusively attended in the centers and 272 (52%) performed some type of home self-analysis; 26 (5%) in urine samples, and 246 (47%) in capillary blood. The estimated mean consumption was of 14 blood sugar strips per patient per month (168 strips/year) and 2.7 glucosuria-glucocetonuria strips (32.4 strips/year). The relative urine/blood ratio was 1/5.2. In 343 cases (65%) some glucoprotein measurement was reported within the last year, 330 (63%) corresponding to glucohemoglobin A1. The mean value was 8.3% (normal: 5-8%). The mean number of applications was 1.6 applications per patient per year., Conclusions: An enormous increase was observed in the amount consumed at the province of reactive material in blood and in the measurement of glucoproteins as the system to assess carbohydrate control in diabetes. A significant reduction was found in the use of reactive strips in urine by the diabetic population.

Background: To analyze the evolution of the use of drugs in diabetes, the consumption of hypoglycemic medication in the province of Tarragona, the autonomic community of Catalonia and Spain as a whole, was studied. A qualitative evaluation of the tendencies of prescription, as an indirect index of quality in the health care to diabetics was performed., Methods: The sales of oral hypoglycemic medication (OH) and insulin (INS) were accounted for in the study environment between 1988-1991. To make consumption uniform a standardized unit of measure was used with defined daily doses (DDD)/1,000 inhabitants/day (Drug Utilization Research Group) of the different groups of drugs. Total consumption was obtained by a primary data source (Intercontinental Medical Statistics), and periodically compared with a secondary source (registry of public prescriptions within Tarragona)., Results: A progressive increase in the consumption of hypoglycemic drugs was observed: 16.1 to 21.2 DDD/1,000 inhabitants/day (31%) in Spain; 17.7 to 19.8 (12%) in Catalonia and 19 to 23 (21%) in Tarragona. The increase in consumption of INS in Tarragona (43%) was greater than that of OH (12%). In Catalonia, it was much greater (INS: 23%, OH: 7%) and was parallel in Spain (36% and 30%, respectively). The OH/INS index decreased in Catalonia and Tarragona (1.3 and 1.9 in 1991) and remained practically constant (2.3-2.4) in Spain. A global decrease was produced in the consumption of slow insulins with a significant increase in intermediate, premixed and fast insulins. A growing increase in glibenclamide much greater than the remaining sulphonylureas was seen, in addition there was a persistent and low use (less than 1 DDD/100 inhabitants/day) of biguanides. Significative variations of medication consumption were registered according to the territory analyzed., Conclusions: From 1988 to 1991 there has been an increase in the use of hypoglycemic drugs. The use of oral hypoglycemics has remained constant in relation to insulins in Spain and in Catalonia and, more so in Tarragona, there is a progressive inclination to the use of insulin. The evolution of consumption suggests important asymmetry in the quality of health care and denotes progression in the global educative offer to diabetics.

Background: With the aim of evaluating the real consumption on insulin an analysis of its loss with use in clinical practice was carried out. The influence of this loss was investigated in the calculations of prevalence of diabetes (DM) initiating from the consumption of medication, the presumable repercussion in public health costs and possible alternatives., Methods: Revision and analysis of the recipients used by a group of 58 insulin treated diabetics was carried out during a mean period of one month. The theoretic consumption, real consumption and the mean loss per each injection according to visual accuracy and the system employed were evaluated. A deduction was made of the autonomy by storing of insulin. A previous calculation concerning the prevalence of DM in Tarragona (548,900 inhabitants) according to consumption was corrected and an economic estimation of the loss demonstrated over public health costs of insulin during 1991 was made., Results: The mean dose prescribed was 39.7 IU/day supplied in 2.4 injections/patient/day. At 30 days (27-35) 310 recipients were evaluated (115 vials/195 boxes). The mean real dose consumed was 53.3 IU/day and the mean loss per injection was 5.6 (25.5% of all the insulin supplied, 4.5% as remnants at the bottom of the recipient). A greater loss was observed by injection a) in patients with reduced sight (6.4 +/- 7.3 IU/5.5 +/- 4.5; NS) and b) in the users of syringes with dead space (5.8 +/- 4.7) with respect to those using an injector insulin pen (4.4 +/- 2.9; p < 0.01). The autonomy by domiciliary storage of insulin was of 103.7 days/patient (prescribed doses) and 78.6 (real consumption). A total of 7 diabetics (12%) had unused expired recipients. The prevalence of insulin treated DM in Tarragona was estimated as around 4.3-4.8/1,000 (2,360-2,635 inhabitants). The expense of loss was 36 million pesetas/year; 6.4 as depreciated remnants of insulin in the bottom of recipients., Conclusions: There is a great loss of insulin in clinical practice which may be avoidable and which influences the public health costs for diabetes. An adequate educative strategy and system of injection independent of user ability would reduce the costs.

Background: This study was carried out to estimate the treatment characteristics and prevalence of diabetes mellitus (DM) diagnosed in the counties of Tarragona (548,900 inhabitants) from the consumption of hypoglycemic medication., Methods: A stratified aleatory sample was made of the prescription of oral hypoglycemic agents (OHA) and insulin (INS) in 14 centers of primary health care. Calculation of pharmacy dispensing and prescriptions (computer network of the Institut Català de la Salut) was carried out with a relation of the mean doses of the survey and the estimate of the consumer population being made. A contrast was made of the system with the daily doses defined (DDD/1,000 inhabitants/day) of the different OHA and INS preparations., Results: Following aleatorization a representative sample of 550 diabetics, 64 (11.6%) type I and 486 (88.4%) type II was obtained. In total, 61 were treated with diet alone (IC 95%; 8-13%, p less than 0.05); 249 (41-49%) with OHA (51% of type II) and 240 (39-47%) received insulin, all the type I and 176 (36%) type II. In 23 cases (2-5%) multiple therapy with different drugs was confirmed and 72 (10-15%) were treated with the maximal doses of OHA recommended. The rate of OHA/INS was 2.02-2.05. The prevalence of pharmaco-treated DM was 1.9% (prescriptions of public health) and 2.1-2.3% (total consumption). The method for DDD was evaluated as between 1.8% (prescriptions) and 2.0% (total consumption). Globally, during 1990 the prevalence of DM diagnosed in Tarragona was estimated as between 2.1-2.5%., Conclusions: The estimation of the prevalence of diabetes mellitus indicated higher numbers than those obtained in other studies providing a first line indicator for the planning of care for diabetics in this demarcation. The study also identified the real therapeutic tendencies permitting the extraction of lines of action for the education of diabetics and the formation of professionals attending these patients.

A health diagnosis made over a two-year period in the basic health area of Falset is described (17 municipalities with populations between 39 and 2,603 inhabitants, making-up a total reference population of 7,283 habitants) in relation to the diabetic population of the Priorato county in Catalunya. This county is geographically heterogeneous, with semi-arid hilly landscape, with poor communications, a farming population and a notoriously hostile climate. The population pyramid, inclined towards progressive aging of the population, is evidence of a major migration from the country. By means of continuous education of health personnel, updating of information sources, improvement of registration systems, and final evaluation, the outlines of an action plan is worked out with a view to the organisation of diabetic care in this rural context. A total of 226 diabetics were counted: 15 type 1 (6.2%), and 211 type II (93.8%). The incidence of diagnosed diabetes in the basic health area is 3.1% (1.4% to 10.33%). The average age of the patients was 65.6 years with a preponderance of women (146 = 64.6%). In 92 patients (40.2%) the evolution time was less than 5 years. The insulinisation rate was calculated at 26.1%. The typical diabetic patient is a retired person or a housewife (87.8), with primary of elementary education (82.7%), supported by the family.

Background: To evaluate the long term efficacy of a program of attention to diabetes mellitus., Methods: A continued 40-month follow-up study in a group of 47 diabetic patients treated with insulin (21 type I and 26 type II) with a mean age of 45.8 years and a mean duration of diabetes of 8.1 years. These patients were seen in the hospital outpatient clinic during the initial 12 months and in community clinics during the remaining 12 months., Results: Mean basal glycemia (7.4 +/- 1.5 mmol/l) and HbA1 (8.3 +/- 1.1%) at 40 months were significantly lower than those in the initial 12 months (8.8 +/- 2.4 mmol/l and 9.2 +/- 1.2%; p less than 0.001) and in the beginning of the study (4.2 mmol/l and 11.2 +/- 1.9%; p less than 0.0001). In type II diabetics, cholesterol and triglyceride levels showed a significant reduction from the mean first year levels (6.2 +/- 0.9 and 1.6 +/- 0.9 mmol/l) to those in the 12-40 months period (5.8 +/- 0.8 and 1.3 +/- 0.5; p less than 0.01 in both instances). Initially, 22 diabetics (46%) used rapid acting insulin; at the end, 37 had included these preparations in their treatment (78%; p less than 0.001). Only 7 patients (14%) used multiple insulin doses at the beginning. After 40 months, 29 (61%) were treated with 3-4 insulin injections per day (p less than 0.0001). In 43 patients (91%) no severe hypoglycemic crisis had developed. In 45 (95%) macroproteinuria was not detected and 40 (85%) had not developed microangiopathic lesions in the retina or microangiopathic involvement elsewhere as evaluated with the available techniques. Psychical depression was evaluated at 40 months using a semiquantitative scale questionnaire. The overall responses in the intervention group (n = 20; 25.4 +/- 4.6) showed lower depression levels (higher scores) than a control group ( n = 22; 22.4 +/- 4.9; p less than 0.02) constituted by diabetics with similar characteristics but who had not been following the program., Conclusions: The programs for the attention to the diabetic are effective in the long term to achieved and sustain metabolic control, the acquired knowledge and, to a sizeable degree, the compliance with therapy, provided that they integrate the teaching with the treatment. It is very likely that these programs reduce the risk of late features of the disease and the tendency to depression, independently from the place where the patient is controlled.

To evaluate a provincial diabetes program for primary care in Tarragona 14 months after its implementation, the data provided by all centers were evaluated. The participants were 8 CAPS and the professionals of a rural area, with a reference population of 170,159. A total of 1,766 diabetic patients were sensed. 131 were type I (7.4%) and 1,635 type II (90.6%). The health care variables of 1,197 patients (67.7%) and the rate of complications of 654 (54.6%) were assessed. A high prevalence of hypertension (50.0%) and dyslipemia (40.5%) were found associated with diabetes. Overall 868 individuals (72.5%) received individualized education in the clinic; 112 of these (12.9%) were included in collective education programs for groups. At the time of this evaluation, the proportion of patients treated with insulin (174/545) was significantly higher than that found before the program (79/402, p less than 0.0001). The practice of glycemic self assessment at home was also significantly increased (82/691 versus 440/1, 124; p less than 0.0001). The initial impact on the professional and diabetic patients of our area has been remarkable. Although the planning of multicentric evaluation systems in complex, it is possible to implement it if the data and recording system are coordinated.

The following were analysed with the object of evaluating a provincial diabetes programme (Institut Català de la Salut. Tarragona Management Areas): a) training activities for professionals in primary health care, and b) some indicators of effectiveness. Between 1987 and 1989, 192 professionals of the institution (89 doctors [46.3%], 85 nursing specialists [44.2%], and 18 members of other health care areas [9.5%]) took part in 8 basic courses on diabetes and diabetological education. A subjective (opinion questionnaires) and objective (written tests) increase in theoretic knowledge was recorded. Continuous counselling from the programme has encouraged the development of 11 initiatives in aiding diabetics (both care and education), in centres in 7 regions in the province of Tarragona, which are presently offered to a reference population of 188,000 inhabitants (30-35% of all users). A provincial census has been started up, with data at present on 2,052 diabetics (189, or 9.3%, type I and 1,863, or 90.7%, type II). A strong increase was recorded in provincial dispensing of insulins by pharmacies (50% higher than in 1985), as well as of material for glucoketonuric and glycemic self-analysis (7-8 times higher than in 1985). Requests for glycosylated hemoglobin from the primary sector rose from 53 in 1986 to 634 over the first six months of 1989. The programme has contributed to enhance the quality of primary aid to diabetics in our regions.