Diabetes care in Slovenia: now and in the future

Historical perspective

Prof Ljudevit Mercun (1900–1954) is regarded as the founder of modern Slovene diabetology. He very soon realised the need for structured diabetes care. After specialisation in internal medicine and additional training in diabetology in Vienna and in Germany, he published an article ‘Modern Diabetes Treatment’ in the Journal of Slovenian Medical Society in which he summarised the basic principles of diabetes diet and insulin treatment. Insulin had been available in Slovenia since 1923.

Prof Mercun's dream came true immediately after the end of World War II in May 1945 when a specialised hospital diabetes department was established as part of the Department of Internal Medicine at Ljubljana General Hospital. As such, it was the first sub-specialised department in the field of internal medicine in Slovenia. In October 1945, the first out-patient diabetes clinic was set up.

After 1950, specialised out-patient diabetic clinics were established in all general hospitals in Slovenia.

Epidemiology

The total population of Slovenia comprises about two million people. The first data on diabetes prevalence in Slovenia are from 1962 and 1964. After 1970, a detailed analysis was conducted but it did not include all of the out-patient clinics.

In 1983, a Diabetes Registry was created and remained functional until 1997. Now it is being reactivated on a modern technology basis. The epidemiological data from the Diabetes Registry and the estimates for the year 2000 are summarised in Table 1. From these data we can estimate that in 2003 the total number of diabetic patients in Slovenia was about 100-000.

Diabetes health care system in Slovenia

Until 1995, the great majority of diabetic patients in Slovenia were treated at secondary and tertiary health care levels. Health care services were provided either by specialists, internists, or general practitioners, both additionally educated in diabetology. The diabetes health care team also included a nurse.

After 1950, specialised out-patient diabetes clinics were set up in all general hospitals in Slovenia. By 1960 their number had increased to 13. After the joint meeting of Slovenian and Croatian diabetologists in Ljubljana in 1963, when the principle of diabetes health care delivery was officially adopted, an additional 19 consulting rooms for diabetic patients were established in health care centres throughout the country.

The spectrum of activities carried out at specialist diabetes clinics has expanded significantly in the last two decades. Much emphasis has been placed upon education and healthy life style promotion. In 1990, the first three out-patient foot clinics were founded. By 2003, a structured foot care prevention and treatment programme had been established in the majority of out-patient diabetes clinics.

Diagnostic facilities for the detection of the late complications of diabetes are widely available and the procedures are carried out according to international guidelines—e.g. screening for diabetic retinopathy by means of fundus photography and screening for microalbuminuria as an early marker of renal impairment. Screening for foot complications has been performed regularly since 1995 when the common foot screening protocol was adopted.

Laser therapy for the advanced stages of diabetic retinopathy is available in all specialist diabetes clinics.

For those patients with end-stage renal failure, renal dialysis is available throughout the country. At tertiary health care level (University Medical Centre, Ljubljana), a special clinic for the patients with end-stage renal failure runs once weekly and co-operates closely with the Department of Nephrology and Dialysis. The good co-operation between the two specialties is also manifest through the fact that kidney transplantation has been carried out successfully in diabetic patients for more than 20 years in Slovenia.

A special programme for diabetic pregnancy had already been started in the early 1980s, including preconceptional consulting, management of diabetic pregnancy and regular screening for gestational diabetes in patients at risk.

Since 1990, an out-patient programme for patients with erectile dysfunction has also been organised, with the co-operation of urologists.

The rapidly growing number of diabetic patients and the increasing demand for good quality service—with regard to not only blood glucose regulation but also all the other aspects of risk factor control—led to an extreme overload of the existing out-patient specialist clinics. In order to reduce this burden, from 1995 onwards the majority of diabetic patients treated either by diet and exercise or oral antidiabetic agents have been transferred to general practice. Most of the insulin-treated patients are still visiting the specialist clinics.

Since the 1990s, insulin therapy has been initiated not only in hospital but more and more on an out-patient basis.

Financial aspects

Diabetic health care in Slovenia is provided free of charge. It includes follow-up examinations, hospital admissions, drugs (oral antidiabetic agents and insulin), injection devices and needles. Blood glucose meters and blood glucose test strips are available free of charge only for insulin-treated patients. Other patients can only get free urine dipsticks and blood glucose test strips for visual reading.

After almost 10 years of negotiations with the health care insurance company and the Ministry of Health, the regulations in the field of specialised footwear improved in 2001; since then special footwear can be prescribed for those diabetic patients who are at highest risk of foot ulcer development.

Now we are working intensively on the regulations regarding the prescription of dressings. At the moment, only conventional dressing materials (cotton gauze) can be prescribed free of charge to patients for home wound care.

Diabetes health care providers

Due to the increasing number of physicians engaged in diabetology, the Slovenian Endocrinology Association was established in 1970. Association meetings are held a year.

In 1979, the Diabetes Committee was founded in order to enforce a uniform doctrine in the field of diabetology and to coordinate the development of diabetes care in Slovenia.

The first postgraduate diabetology courses for doctors were set up in 1982 and 1983. Since 1995 short postgraduate diabetology courses for general practitioners have been organised twice a year. Those physicians who intend to run out-patient diabetes clinics are educated in three-month courses at the Department of Endocrinology, University Medical Centre, Ljubljana.

The Slovenian Nurse Endocrinology and Diabetology Association was founded in 1988. Postgraduate diabetology courses for diabetes nurses have been run twice yearly since 1996.

The Slovenian Diabetic Foot Working Group was established in 1995 to enforce the development of the network of diabetic foot clinics and to promote research.

Since 1995, training courses on diabetic foot care for physicians, nurses and pedicurists have been carried out once a year, followed by practical training at the out-patient diabetic foot clinics. An educational programme for podiatrists at the University of Ljubljana has not yet been established.

We still lack dietitians and clinical psychologists, although the first steps in this direction have been made recently.

Membership of international associations

Slovenian physicians and nurses are members of numerous international diabetes associations: European Association for the Study of Diabetes (EASD), American Diabetes Association (ADA), Mediterranean Group for the Study of Diabetes (MGSD), International Diabetes Federation (IDF), Gesellschaft für Nephrologie (GFN), Deutsche Diabetische Gesellschaft (DDG), Federation of European Nurses in Diabetes (FEND). They are also active members of the EASD study groups: Diabetes Education Study Group (DESG), Diabetic Foot Study Group (DFSG), Psychosocial Aspects of Diabetes (PSAD) and European Diabetic Nephropathy Study Group (EDNSG).

In 1994, the 4th Alpe-Adria Workshop on Diabetes Mellitus was held at Rogaπka Slatina. In 1996, a satellite EASD symposium on hypoglycaemia was organised at Bled and in 1998 and 2002, the 1st and 2nd Slovenian Endocrinology Congresses took place.

Patients' associations

The first society of diabetic patients was founded in Ljubljana in 1956, followed by 38 more in other places in Slovenia in the following years. They are brought together under the umbrella of the Slovenian Diabetic Association.

Publications

We have taken an active part in the International Working Group on the Diabetic Foot which prepared the International Consensus on the Diabetic Foot in 1999 and the update CD-rom in 2003.

Plans for the future