Transcript Pharmacological Agents Used In The Treatment Of Diabetes

The Multi-disciplinary Diabetes Centre :
A Model of Care for the Future (or the Past) ?
Dennis Yue
Director of Diabetes, Royal Prince Alfred Hospital
Kellion Professor of Endocrinology, University of Sydney
Conference in China
The Burden and Complexity of Diabetes
Different Models of Diabetes Care
Diabetic
Clinic
Care
Diabetes
Centre
Diabetic Clinic Care +
Annual Complications
Screening
Complications Screening
in 12 months (%)
Eyes review
88
100
86
Lipids Measurement
72
96
92
Microalbuminuria
56
94
72
Cholesterol < 4mmol/L
24
24
27
BP
26
35
28
HbA1c within 1% of
normal range
29
44
41
Target Achieved (%)
ANDIAB Survey : Cheung NW et al : Diabet Med 2008 ; 25(8) : 974-8
We Must Have A Centre !
A Multi-disciplinary Diabetes Centre
Family Doctor
Podiatrist
Dietitian
Person with
Diabetes
Researcher
Specialist
Secretaries
Diabetes Nurse
/ Educator
What We Need Is Not A Diabetes Education Centre
A Multi-disciplinary Diabetes Centre
(Education is Integrated with Clinical Service and Care is Shared)
Referring Doctor
Pregnancy
Clinic
Waiting time
6 months
Waiting time
0 to 2 weeks
Acute Intervention
Clinic
High Risk
Foot Clinic
Complications and
Metabolic Management
(Type 1 & 2)
Follow-Up Clinic
Review Clinic
Within
4 months
Referring Doctor
Hoskins PL : Diab Med 1993; 10(1) : 81-6
Overland J et al : Diabetes Res Clin Pract 1999 ; 44(2) : 123-8
Constantino M et al : Med J Aust 1991 ; 155(8) : 515-8
One Stop Complications Assessment
McGill M et al : Diabet Med 1993 ; 10(4) : 366-70
McGill M et al :Diabetes Care : 1989 ; 12(8) : 599-600
Standardised Data Capture
Younger Onset of Type 2 Diabetes
Increases Risk of Retinopathy
Wong J et al : Diabetes Care 2008; 10 : 1985-90
Beyond ONTARGET :
(Deterioration of renal function while on combined
ACE-I and A2 Receptor Blocker Treatment )
Hypertension (BP < 160/100)
Hypertension (BP > 160/100 )
J Wong et al : Diabetes Obesity and Metabolism 2010
Ambulatory Stabilisation of Diabetes :
Commencing Insulin Therapy
Hoskins PL et al : Med J Aust 1993 ; 158(3) : 148-9
Telephone Stabilisation
Genev NM et al Diabet Med 1990 ; (1) : 920-1
Changing Pattern of Treatment of Type 1 Diabetes :
More Use of Carbohydrate Counting and Insulin Pump
Continuity of Care in a Multi-disciplinary Setting
Patient 1
Visit 1
Visit 2
Visit 3
Visit 4
Patient 2
Standardised Format of Letters
(Documentation and Education)
Infrastructure Support
Monitoring By A Senior Nurse After Visits
• Daily team clinical meeting
– All patients’ medical
record reviewed ; possible
mistakes identified and
appropriately questioned
– Standardises party line
message and upskill staff
– Collects data
The High Risk Diabetic Foot Clinic
A Co-ordinator Who Knows Everything
McGill M et al : Intern Med J 2005 ; 35(8) : 451-6
Nube VL et al : The Diabetic Foot Journal 2008 ; 11, 187-193
Benefits of Multi-disciplinary Foot Clinics
(RPAH): Prevalence and Level of Amputation
2 =14.6; P=0.001
90
Clinic
80
No Clinic
70
60
50
40
30
20
10
0
Distal
Below Knee Above Knee
McGill M et al : Intern Med J 2005 ; 35(8) : 451-6
Nube VL et al : The Diabetic Foot Journal 2008 ; 11, 187-193
How Does Telemedicine Work?
Dubbo
Lismore
Nowra
Orange
Grafton
Port Macquarie
Griffith
Forbes
Quirindi
Mullumbimby
E-mail
High Risk
Foot Clinics
•Medical Data
McGill M & Constantino M et al : Practical Diabetes 2000 ; 17(7) : 235-238.
Clinical Trials
Why is the Multi-disciplinary Diabetes Centre a
Better Model for a Chronic and Complex Disease ?
• A more stable system than one dependent on rotating
doctors
• Complement better the skill of allied health professionals
and doctors ; therefore a broader range of expertise
• Better stratification and triaging of patients
• Facilitate communication
• Better facilities for service between visits
• More flexibility internally (diversified staff skills and
training) and externally (referring doctors pick what they
want)
• Can be as good as an excellent doctor and can serve more
people
The Power of Computer
The Under Water Volcano Theory of GDM
Ethnic Susceptibility to GDM is a Function of Ethnic Difference
in Age of Onset of Type 2 Diabetes
Ross GP et al Diabet Med ; 13(8) : 748-52
Long-term Efficacy Of Metformin Treatment In
Non-obese Individuals With Type 2 Diabetes
Ong CR et al ; Diabetes Care 2006 ; 29(11) : 2361-4
Metabolic Syndrome in Type 1 Diabetes
McGill M et al : J Diabetes Complications 2008 ; 22(1) : 18-23
Strong Family History Predicts A Younger Age Of
Onset For Subjects Diagnosed With Type 2 Diabetes
Molyneaux L et al : Diabetes Obesity and Metabolism 2004 ; 6 : 187-94
A Transplant of Diabetes Centre to Rural Area
Overseas Collaborations
Fiji and Kirabati
China
Liu DP et al Diabetes Res Clin Pract 2002 ; 56(2) ; 125-31
Wong, J et al : Journal of Diabetes and Complications 2008 ; 22 : 389-394
Hoskins PL et al : Diabetes Res Clin Pract 1987 ; 3(5) ; 257-67
Hoskins PL et al : diabetes Res Clin Pract 1987 ; 3(5) : 257-67
Training and Exchange Programs
National and International
Clinical Research and Basic Science Research
Biomedical Research on Diabetic Complications
Brooks B et al : Diabetes Care 1999 ; 22(10) : 1722-7
Brooks B et al : Diabet Med 2001 : 18(5) : 374-80
Brooks B et al : J Clin Endocrinol Metab 1994 ; 79(6) : 1681-5
Brooks BA et al : Diabetes Obes Metab 2008 ; 10(9) ; 739-46
Skin Biopsy to Assess Small Fibre Diabetic Neuropathy
Sorensen L et al : Diabetes Care 2006 ; 22(3) : 261-5
Magnetic Resonance Spectroscopy in the
Study of Diabetic Neuropathic Pain
B.
C.
D.
NAA
Cr/PCr
mI Cho
Gluc
Glx/GABA
Sorensen L et al : Diabetes Care 2008 ; 31(5) : 980-1
Relationship Between Age of Diabetes Onset
and Mitochondrial DNA Content
No comps
r=0.7:p=0.0002
Comps
r=-0.04:p=0.8
Wong J et al Diabetologia 2009 ; 52(9) : 1953-61
Wound Fluid MMP-9 and TIMP-1 Levels
Predict Poor Wound Healing
MMP-9 (μg/ml)
10
*
8
Ratio of MMP-9/TIMP-1
Healed
Unhealed
6
*
4
2
0
pro-MMP-9
act-MMP-9
MMP-9/TIMP-1 (x100)
MMP-9
25
20
Healed
Unhealed
**
15
10
*
5
0
pro-MMP-9/TIMP-1
act-MMP-9/TIMP-1
* p<0.05, ** p<0.01 different from healed within 12 weeks
Liu Y:- Diabetes Care 2009 ; 32(1) : 117-9
Xu, L et al Diabetes Care 2007;30(2):378-80
The Relationship of Monocyte Surface
Markers with Diabetes and Retinopathy
Min D et al : American Diabetes Association Meeting 2010
Research in a Multi-disciplinary Setting :
Less linear than thematic
The Interactive Multi-disciplinaryTeam
Doctor
Doctor Nurse
Nurse
Dietitian
Dietitian
What is an Interactive Team ?
Weekly Training Sessions
The Nurses and Other Allied Health Professionals
• A wider horizon
• On the job training according
to ambition and skills
• Better rewarded
• More demanding (The
Nuremberg Principle)
• The seven most senior nurses
have worked at the Diabetes
Centre for a total of 160 years
Professional Development and Achievements
• Allied health professionals were 1st author in more than 70
publications in international peer reviewed journals
• 3 PhD, 4 MSc, 1 MPH
• Two employees of the month (Information Technology and High Risk
Foot Clinic)
• 1 statistician to an international peer review journal
• Lilly Award (The Unsung Heroes)
• Best High Risk Foot Podiatrist (NSW) Award
• Chairperson of the NSW Health Telemedicine Committee
• The first two Nurse Practitioners in diabetes in NSW
• 3 Associate Professors
• 1 IDF Senior Vice-President
• 2 Board Members of JDRF
• Other Grants and Awards
• 12 babies !!!
The Doctors
• Take responsibility
• Contribute to leadership and
vision
• Training of staff
• Do the things that allied health
professionals cannot do,
according to a sliding scale
The Diabetes Centre Model of Care
Royal Prince Alfred Hospital
The Italian Way
If you never never go, you will
never never know
Rome was burnt in one day in
AD 64
A Model in Danger of Evolutionary
Extinction
Number Of Patient Services Per Year
Cost and Output (2008)
1. About one-third self generated (clinical trials,
clinical services, training of health professionals,
grants)
2. Our current capacity can see about 23% of known
cases in our area.
National Health Care Reform
• Focus diabetes treatment at the Primary Care
Level
• Diagnostic Related Groups used to evaluate
efficiency of hospital and determine funding
• Where does Diabetes Centre sit on this ?
Organization of the Diabetes Movement
Thanks for the Family !
A Chance Meeting