Estrategia en Diabetes del Sistema Nacional de Salud

Objectives

Spain’s Diabetes Strategy provides a common National Health System framework to reduce inequalities, promote health and healthy lifestyles, improve quality of care, and achieve equitable, clinically effective diabetes care irrespective of place of residence. It seeks realistic, evidence-informed improvements in the quality and outcomes of interventions, within available resources and the responsibilities of the autonomous communities.[1][2]

• Reduce the incidence of type 2 diabetes by addressing obesity, physical inactivity, unhealthy diet, hypertension, hyperlipidaemia and impaired glucose tolerance.[3][4]
• Promote healthy lifestyles and primary prevention, including nutrition, physical activity, fruit and vegetable consumption, public awareness, and prevention of progression from impaired glucose tolerance to type 2 diabetes.[4][5]
• Strengthen early diagnosis through opportunistic detection in people at risk, rather than population-wide screening, and improve screening for carbohydrate-metabolism disorders during pregnancy.[6][7]
• Improve treatment and follow-up by combining glycaemic management with control of cardiovascular risk factors, pharmacological treatment, lifestyle change, health education and self-management.[7][8]
• Reduce microvascular and macrovascular complications, including cardiovascular and cerebrovascular disease, amputations, renal failure, blindness and premature mortality.[9][10]
• Provide tailored care for children and young people, pregnant women, older people, and population groups with higher diabetes prevalence or particular sociocultural needs.[11][12][10]
• Strengthen training, research and innovation, including clinical, epidemiological, molecular, therapeutic and health-services research, and accelerate translation of findings into practice.[13][14][15]

The strategy covers five principal strategic lines: healthy lifestyles and primary prevention; early diagnosis; treatment and follow-up; management of complications and special situations; and training, research and innovation. Information and evaluation systems provide a cross-cutting framework for monitoring these areas. The framework includes seven general objectives, 20 specific objectives and 20 evaluation indicators.[2][16]

Implementation

Implementation relies on coordinated action across the Ministry of Health and Consumer Affairs, autonomous-community health services, scientific societies, patient associations, professionals, and other public and community actors. The Strategy was approved by the Interterritorial Council of the National Health System on 11 October 2006, and autonomous communities are expected, where feasible, to implement the agreed elements judged to have the greatest effectiveness and impact.[1][17]

• Coordinate governance through the Ministry’s Directorate-General of the Quality Agency and Office for Health Planning, supported by the Scientific Coordinator, the Health Information Institute, the Directorate-General for Cohesion and Quality, technical experts and external advisers.[2]
• Use a Technical Drafting Committee to assess needs, define strategic lines and common objectives, identify evidence-based indicators, and prepare recommendations.[2][16]
• Engage an Institutional Committee representing the autonomous communities and the National Institute for Health Management, responsible for Ceuta and Melilla, to assess relevance, feasibility and organisational viability.[16]
• Build consensus through documentary reviews, surveys, joint meetings and review by scientific societies and national and international bodies; include only objectives and indicators receiving explicit unanimous agreement from the autonomous communities.[2]
• Deliver population-level prevention through collaboration with education and sports authorities, local councils, schools, associations, health centres and food-industry organisations, including health-promotion materials, healthier collective catering and opportunities for physical activity.[4][5]
• Target risk-based detection at people with obesity, family history, hypertension, dyslipidaemia, previous gestational diabetes, adverse obstetric history, impaired fasting glucose or impaired glucose tolerance, linked to lifestyle and cardiovascular-risk advice.[6]
• Organise integrated care through agreed protocols and clinical practice guidelines connecting primary, specialised, emergency, surgical and maternity services, alongside structured diabetes education and support for self-management.[9][11][18][19]
• Develop multidisciplinary teams for complex complications and special situations, involving primary and specialist nursing, public administrations, patient organisations, family doctors, midwives, endocrinology and gynaecology specialists where relevant.[18]
• Strengthen professional development through continuing education and primary-specialised care consultation, and support co-operative research networks and integrated research units across autonomous communities.[19][14][15]

Monitoring depends on harmonised indicator definitions and comparable arrangements for recording, aggregating and interpreting information. The Health Information Institute coordinates data collection and development of unavailable indicators with support from the National Health System Subcommittee on Information Systems, which includes all autonomous communities and reports to the Interterritorial Council.[20]

• Collect and publish progress information under the National Health System Quality Plan, including autonomous-community annual descriptive reports on health-promotion actions and their evaluations.[20][21]
• Use National Health Survey data, primary-care registers, hospital discharge records, transplant data, population projections and mortality statistics to monitor prevention, diagnosis, treatment outcomes, complications, transplantation, mortality, training and publicly funded research.[22][23][24][25]
• Report key measures at defined intervals, including biennial monitoring of obesity, physical activity, diet, declared and diagnosed diabetes prevalence, cardiovascular risk factors and clinical-guideline quality.[26][21][22]
• Assess glycaemic control every three years, acute-complication discharges every two years, pregnancy-related diabetes complications and premature mortality annually, and kidney and pancreas transplantation biennially.[23][27][24][25]

Monitoring & Evaluation

The strategy establishes a national monitoring and evaluation framework based on 20 prioritised indicators, intended to assess implementation across prevention, diagnosis, treatment, complications, training, research and innovation. Indicators were selected through consensus, assessed for relevance and feasibility, and approved unanimously by Spain’s autonomous communities.[2][17]

• Coordinate indicator development and information collection through the Institute of Health Information of the Quality Agency, supported by the National Health System Subcommittee on Information Systems, which includes autonomous-community representation and reports to the Interterritorial Council.[20]
• Harmonise indicator definitions, recording, aggregation and interpretation criteria to improve comparability between territories and care settings.[20]
• Publish monitoring and evaluation results in line with the Quality Plan for the Spanish National Health System.[20][26]
• Require autonomous communities to provide annual descriptive reports on health-promotion activities, including interventions, methods, target populations and available evaluation results.[21]

Population prevention indicators use the National Health Survey biennially to measure overweight and obesity, physical activity, and daily fruit and vegetable consumption, with disaggregation by autonomous community, sex and age group.[26][21]Screening coverage measures the proportion of people aged over 14 who are considered at risk and have received relevant diabetes testing, including screening linked to cardiovascular-risk assessment and O’Sullivan testing during pregnancy.[21]

The strategy also specifies care-process and outcome monitoring. Declared diabetes prevalence is measured biennially through the National Health Survey, while diagnosed prevalence is measured through primary-care information systems using agreed common data criteria.[22]Cardiovascular risk factors among people with diabetes, including hypertension, hypercholesterolaemia, obesity and smoking, are monitored every two years.[22][23]

• Assess the quality and dissemination of diabetes clinical-practice guidelines every two years.[22]
• Track hospital discharges for acute complications, including ketoacidosis and diabetic coma, every two years by autonomous community, age, sex and complication type.[23]
• Measure good glycaemic control as the proportion of diagnosed patients with a latest glycated haemoglobin result below 7%, reported every three years; measure poor control as the proportion of tested patients with a result above 9%.[23][27]
• Monitor non-traumatic lower-limb amputations using hospital discharge data, reported per 1,000 estimated people with diabetes and disaggregated by territory, age and sex.[27]
• Measure pregnancy-related complications annually, kidney transplantation biennially, premature diabetes mortality annually, pancreas transplantation biennially, and publicly funded diabetes research projects annually.[24][25][28]

Data sources include hospital discharge records, primary-care diabetes registers, the National Health Survey, the National Transplant Organisation, and population and mortality statistics from the National Statistics Institute.[24][25]The framework recognises limitations in existing registers, including uneven availability, limited precision, restricted dissemination and poor harmonisation between settings and territories.[29]Some prospective indicators were not prioritised because of validity, operational usefulness or feasibility constraints, and further data-exploitation systems are envisaged.[25]

The supplied material does not set out a comprehensive reporting timetable for all indicators, named bodies accountable for performance, audit procedures, enforcement mechanisms or quantified targets beyond selected clinical measures.[17][16][9]

Costing & Financing

The strategy does not provide a comprehensive implementation budget, detailed programme costings, funding-gap estimate, resource-mobilisation plan or general economic assumptions. It frames objectives as needing to be realistic in relation to available resources and the responsibilities of autonomous communities.[2][30]

Diabetes is characterised as imposing substantial social and health-system costs, particularly because of chronic complications, hospital admissions, readmissions and longer hospital stays.[31]For type 1 diabetes, resource use initially focuses on outpatient care, medicines and self-monitoring materials, while costs are reported to double after the early period because of hospital treatment for complications.[32]

• Record a mean direct cost of 1,305 euros per patient per year for type 2 diabetes managed in primary care in the CODE-2 study.[32]
• Attribute 42% of this estimated direct cost to medicines, 32% to hospitalisation and 26% to outpatient care.[32]
• Identify cardiovascular complications as accounting for 47% of the additional cost of diabetes care.[32]
• Report an average hospital stay that is 3.1 days longer and a rehospitalisation probability that is 67% higher for people with diabetes.[32]

The evidence base describes opportunistic detection among risk groups and lifestyle prevention for impaired glucose tolerance as cost-effective, but provides no monetary estimates, thresholds or modelling assumptions for these interventions.[4][6]Selected research priorities require cost-benefit or cost-effectiveness analysis, including lifestyle prevention, exercise-promotion models, telemedicine, insulin delivery technologies, sensors and new medicines.[33][34]

Research financing is the principal quantified resource allocation in the supplied material. Between 2000 and 2005, 166 of 369 diabetes research proposals submitted to the Ministry of Health and Consumption and the Carlos III Health Institute programme received awards totalling 8.7 million euros, including indirect costs.[33]The Directorate-General of the Quality Agency also commissioned 1.5 million euros of specific financing for research into prevalent diseases, including diabetes, with repetition planned in subsequent years.[33]

Public financing channels for diabetes research include the Carlos III Health Institute, the Ministry of Health and Consumer Affairs, and direct funding from autonomous communities.[25][28]No allocations by strategic line, implementation period, institution or autonomous community are specified, and no national funding gap is quantified.[33][25]