Manual para el diagnóstico y tratamiento del paciente diabético a nivel primario de salud

Objectives

The manual establishes a comprehensive Cuban diabetes-care framework spanning prevention, early detection, diagnosis, treatment, rehabilitation and prevention of acute and chronic complications. Its overarching aim is to prolong life and preserve quality of life through near-normal metabolic control, risk-factor management, therapeutic education, supported self-management and multidisciplinary care.[1][2]

• Prevent or delay diabetes by promoting healthy weight, physical activity, healthier diets, avoidance of harmful habits and management of modifiable risk factors among people at risk or with impaired glucose regulation.[3][4][5]
• Detect diabetes early through active, risk-based case-finding, systematic testing and confirmation of abnormal glucose results, including universal screening for gestational diabetes.[6][7][8]
• Achieve individualised metabolic control while avoiding severe hypoglycaemia, with clinical targets for glucose, glycated haemoglobin, blood pressure, body weight and lipids.[9][10][11]
• Prevent, identify and manage retinopathy, nephropathy, neuropathy, cardiovascular disease and diabetic foot complications, alongside acute hypoglycaemia, ketoacidosis and hyperosmolar decompensation.[12][13][14]
• Provide life-course care for children, adolescents, women planning pregnancy, pregnant women, adults and older people, including attention to reproductive, psychosocial and climacteric health needs.[15][16][17]
• Use primary, secondary and tertiary prevention respectively to reduce disease onset, secure early diagnosis and control, and limit disability and premature mortality from complications.[5]

Implementation

Implementation is organised through Cuba’s interconnected three-level public health system, led by primary healthcare and supported by diabetes care centres, regional hospitals, institutes and terminal hospitals. Family doctors and nurses register and follow the population, undertake prevention and active screening, begin routine care, provide education and coordinate referral and counter-referral; specialist services manage complex, acute, pregnancy-related and advanced-complication cases.[15][7][18]

• Deliver routine care through family doctor and family nurse practices, including clinical history, examination, metabolic records, laboratory testing, lifestyle counselling, review of injection and glucose-meter technique, and assessment for chronic complications.[19]
• Use comprehensive diabetes consultations and diabetic care centres to adjust treatment, provide basic and repeat therapeutic education, arrange ophthalmological, podiatric and dental assessment, and return stable patients to primary care.[20][16]
• Apply a stepped care model combining diet, physical activity and medication, escalating from non-pharmacological measures to oral medicines, combination therapy or insulin according to obesity, glycaemia, ketosis, clinical stability and response to agreed targets.[2][21][22]
• Tailor insulin therapy to clinical need, including type 1 diabetes, inadequate type 2 diabetes control, pregnancy, acute decompensation, intercurrent illness and perioperative care; intensive therapy requires trained patients, self-monitoring and multidisciplinary support.[23][24][25]
• Provide continuing individual or group therapeutic education on food planning, physical activity, medicines, insulin administration, blood or urine self-monitoring, hypo- and hyperglycaemia, foot care, complication recognition, and sexual and reproductive health.[2][26]
• Support personalised nutrition through assessment of nutritional status, body mass index, waist circumference, energy needs, activity and treatment regimen, with dietary plans adapted to personal circumstances and cultural preferences.[27][28][29]
• Prescribe exercise after physical, ophthalmological, neurological and cardiovascular assessment, adapting activity to glucose control, hypoglycaemia risk, neuropathy, retinopathy, footwear and other complications.[30][31]
• Coordinate preventive action beyond clinical services through community outreach, schools, older people’s groups, volunteer activists and intersectoral collaboration involving agriculture, media, sports institutions and catering services.[4][5]
• Refer children and adolescents to paediatric endocrinology, pregnant women to diabetes-and-pregnancy services, women planning pregnancy to preconception services, and people with difficult control or complications to appropriate specialist care.[16][32][17]

Clinical follow-up relies on self-monitoring and laboratory assessment of blood glucose and glycated haemoglobin, complemented by measurement of blood pressure, lipids, weight, renal function and complication-specific findings. HbA1c is recommended at diagnosis and generally every three months, with twice-yearly testing possible for some people with good control.[33][34][10]Retinal examination is integrated into primary care and specialist services, with annual assessment from five years after type 1 diabetes diagnosis and from diagnosis for type 2 diabetes.[35][36]Renal surveillance includes proteinuria, microalbuminuria, serum creatinine and estimated glomerular filtration, while foot assessment includes neurological, vascular and lesion-severity examination.[37][38][39]

Scheduled reviews include at least annual assessment for people with type 1 or type 2 diabetes, every three or four months for severe chronic complications, six-monthly dental review when asymptomatic, two-monthly podiatric care for high-risk feet and periodic nursing home visits to assess self-care, psychosocial adaptation, diet, exercise and insulin storage.[16][19][8]The extracts define clinical monitoring and referral mechanisms but do not specify a consolidated national reporting schedule, formal programme indicators, audit process, named accountability body, implementation timeline or budget.[7][20][5]

Monitoring & Evaluation

Monitoring is primarily clinical and integrated across Cuba’s three-level public health system: family doctor and nurse practices maintain population registration, conduct active case-finding and follow-up, while polyclinics, diabetes care centres, hospitals and specialist services provide escalating assessment, treatment adjustment and referral.[15][7][18]Formal programme-level reporting schedules, audit arrangements, named accountability bodies and population performance targets are generally not specified.[15][7]

• Conduct risk-based diabetes screening, including at least three-yearly testing for people aged 45 years or over and younger people with overweight and additional risks; undertake annual glycaemic follow-up when an abnormal result does not confirm diabetes.[6][3]
• Use fasting glucose, random glucose and oral glucose tolerance tests for diagnosis and classification; confirm diabetes or prediabetes with repeat qualifying testing in asymptomatic people.[40][6][3]
• Monitor metabolic control through capillary glucose self-monitoring, periodic fasting and post-prandial venous glucose, and glycated haemoglobin (HbA1c). HbA1c testing is recommended at diagnosis and every three months, although twice-yearly testing may suffice for some people with good control.[33][41][34]
• Use HbA1c categories of good control at 6–6.5%, acceptable control at 6.5–7%, and poor control above 7%, while individualising glycaemic targets because intensive control can increase severe hypoglycaemia risk.[34][10]
• Track non-glycaemic cardiovascular and renal parameters, including body mass index, waist circumference, blood pressure, lipid concentrations, microalbuminuria, serum creatinine and estimated glomerular filtration rate.[28][10][11]
• Review abnormal glucose readings for dietary intake, physical activity, illness, medicine effects, insulin administration and equipment issues, then adjust treatment where appropriate to prevent recurrent hypo- or hyperglycaemia.[11][42]
• Require at least four daily capillary glucose measurements for intensive insulin therapy, alongside monitoring of HbA1c, severe hypoglycaemia and chronic-complication outcomes. The intensive-therapy targets include mean glucose no higher than 7.8 mmol/L, HbA1c below 6.5%, and a reduction in chronic complications of at least 50% over five to ten years.[24][9]
• Monitor hospitalised and perioperative patients more intensively, including at least hourly glucometer testing during surgery and targets of 7–11.1 mmol/L during intercurrent illness or 8.3–11.1 mmol/L during complex or emergency surgery.[25][43][44]
• Apply close monitoring in hyperosmolar states and diabetic ketoacidosis, including hourly blood glucose, urine output, pH, osmolarity, hydration and electrolyte assessment. Acute resolution is defined by pH above 7.3 and/or osmolarity below 330 mOsm/L, absence of hypovolaemia and glucose at or below 13 mmol/L.[45][46]
• Undertake complication surveillance through annual retinal examination for type 1 diabetes from five years after diagnosis and for type 2 diabetes from diagnosis, with more frequent ophthalmological follow-up according to retinopathy severity.[35][36][14]
• Confirm suspected diabetic nephropathy through repeated albuminuria testing: two positive results out of three over three months establish microalbuminuria. Monitor renal decline and refer for specialist care when deterioration exceeds 5 mL/min over six months or creatinine clearance is below 30 mL/min.[38][47]
• Assess neuropathy and diabetic-foot risk through neurological and vascular examination, monofilament and vibration testing, pulse examination, ankle-brachial index, ulcer classification and relevant laboratory investigations.[48][49][39][50]
• Maintain scheduled continuing care, including at least annual diabetes review, three- or four-monthly review for severe chronic complications, six-monthly dental review, two-monthly podiatric review for high-risk feet, annual fundoscopy, and nursing home visits at least annually.[16][19][8]
• Evaluate diabetes education after the basic course and provide repeat consultation where education remains inadequate or metabolic control is poor, returning patients to primary care once expected educational and metabolic outcomes are achieved.[16]

Costing & Financing

The material recognises diabetes as a substantial economic burden for individuals, families, the health system and society, but does not provide a consolidated budget, costed implementation plan, financing source, resource-mobilisation strategy, funding gap, allocation or economic assumption.[1]

• Identify the cost of glucometers and reagent strips, as well as the education and training needed to use them, as barriers to self-monitoring in some settings.[33]
• Recognise that combined neurological and electrophysiological assessment for diabetic neuropathy is costly, although it is not considered indispensable for diagnosis.[48]
• Consider economic circumstances as a potential barrier or contraindication to intensive insulin therapy, without quantifying the financial implications.[9]
• Consider medicine costs alongside effectiveness, mechanism of action, adverse effects and contraindications when selecting treatment, although no prices or expenditure figures are supplied.[21]
• Recognise cardiovascular disease as an important contributor to the direct and indirect costs of diabetes, without monetary estimates.[10]
• Note that the described primary, secondary and tertiary care structure, specialist referrals, laboratory testing, monitoring equipment, education and complication services have no associated resource allocation or financing details in the supplied text.[15][20][16]