Dr. Jesús Blanco: “For the follow-up of patients with diabetes, the ‘one-size-fits-all’ approach does not make sense"

The current working structure consists of a multidisciplinary Management Committee made up of 11 members of the Unit and 13 Working Groups. Each working group defines the programmes and procedures required in each of the different areas and this allows for multiple initiatives that generate specific in-depth knowledge. This streamlines the management and improves the quality of the Unit’s projects.

This restructuring means that there is an increasingly unclear hierarchy, and that a single figure is not "burdened" with all the work, but rather tries to divide the tasks into small working groups that have a certain degree of autonomy.  Nevertheless, each of the groups has a leader and coordinator who is responsible for acting as a link and disseminating the work being done in the working group to the Management Committee.

All areas are subject to this innovation.  If I were to highlight one that concerns the Endocrinology Service directly, it would be the care of diabetes when it starts at an early age, which we have stipulated as being below 50 years old.  It is known that people with early-onset diabetes are at much higher risk of developing other diseases and associated complications. This means it is essential to identify them, manage them and provide them with the best treatment as early as possible.

This concept comes from the philosophy that what we should prioritize is the identification of the population that can benefit most from each of the treatments, ensuring that they are managed appropriately.  This is over and above or in addition to all the progress that is being made with new treatments. For example, if we know that only 10% of people with diabetes develop it at an early age, we have a very restricted population but one that should be treated very early and intensively to avoid all the associated complications. In this way, we shall not only use more effective treatment strategies and drugs, but also target them at the population that will benefit most.  All in all, this should help us reduce the burden of disease associated with diabetes.

In this respect, work is underway on a scorecard that identifies outpatients who could benefit from some of the processes linked to the Unit. To date, 8,000 patients have been identified, and this will allow us to evaluate different indicators that are essential for improving the current processes.  

The scorecard will not only be associated with having more up-to-date information on the condition of our patients, but also with generating a segmentation tool for the person with diabetes.  Basically, there is no such thing as diabetes as such, but instead there are many variants of the different types.  However, up to now, we have followed an inertial and homogeneous scheme for the follow-up of patients with diabetes, but this ‘one-size-fits-all’ approach does not always make sense.

There are patients who are so well controlled that one annual visit would be enough, whilst others need a follow-up every 3 months instead of the 6-monthly visits that are normally stipulated for everyone.  Or there are even people who usually do well but who then have a specific incident and need to be seen at that time.

This can be achieved with glucose monitoring systems, which today we can access remotely with information updated daily and practically in real time.  We are incorporating the world of telemonitoring into the field of chronicity, which is not as common as in that of home hospitalization. We shall be implementing this organizational healthcare change in the coming months.   

In fact, the Young People's Diabetes Unit Working Group aims to implement this new care protocol.  This will be carried out in collaboration with primary care colleagues (both medical and nursing staff), who have a crucial role to play.  With all the tools in place, effective treatment will be generated and established that is also very targeted at this population with a high risk of complications.

Yes, in recent years some drugs have been optimized, especially for type 2 diabetes, drugs that were already on the market but which have improved their delivery system and, therefore, the quality of life of patients.  For example, going from daily to weekly administration or from injectable to oral tablet form.

New drugs are also about to arrive that are expected to not only reduce the risk of complications of the disease, like current treatments, but also to change the natural history of the disease. These affect weight loss and the evidence tells us that, with a 10-15% reduction in weight, the progression of the disease can be halted.  Until now, weight loss has been achieved mainly through dietary and lifestyle changes, which are often not easy for patients to implement.  Some of the treatments recommended by the doctor for diabetes even resulted in weight gain, which contradicted the therapeutic goal.  Weight loss, along with glycaemic control, has always been a therapeutic goal for us. However, we lacked the tools to achieve it. With these new drugs, the basic idea is to try to help and to nudge them in the same direction, and to ensure they are catalytic treatments that help the patient to make these lifestyle changes with visible results.

We could also talk about new technologies, like insulin infusion systems, such as what we call the artificial pancreas or pseudo pancreas, more focused on type 1 diabetes. These systems include an algorithm that analyses the information from the glucose sensor and makes the insulin infuser increasingly automatic, thus improving the patient's quality of life.

Nowadays, from the very start, we try to take four basic aspects into account in order to have an impact on the natural history of the disease, both the patient and the health professionals:

The first is that it is a metabolic disease and, as such, it is associated with cardiovascular complications, which must be controlled and treated as a priority. Cardiovascular risk, blood lipids, hypertension, tobacco consumption, exercise, etc. must be controlled.  On the other hand, an essential factor in the evolution of the disease, as we have mentioned, is excess body fat, which must also be treated as a priority. In this respect, weight loss must be a priority objective that the patient must be aware of. Both the first and second objectives must always go hand in hand.

On the other hand, the third aspect, which is traditionally emphasized, is the control of blood sugar or glycaemia.  Finally, the fourth crucial aspect is the efficient use of drugs that help control each of the other three aspects mentioned above.  In this respect, the new drugs and treatments that are coming out are helping us a lot.  

Yes. As I said, all these advances in treatment are very important, but it is the professional's responsibility to use them as efficiently as possible at the right time. The management and treatment of diabetes should be prioritized in the early stages, when there are no complications or associated diseases, because by the time we reach those stages, it is too late.  In that respect, these new programmes, which try to profile and segment patients and identify those patients at risk early, are very important.  And here, primary care has a fundamental role to play.