Diabetes and Chronic Diseases Preventing the Preventables

Size: px

Start display at page:

Download "Diabetes and Chronic Diseases Preventing the Preventables"

Stephen Short
5 years ago
Views:

1 Diabetes and Chronic Diseases Preventing the Preventables Juliana CN Chan Professor of Medicine and Therapeutics On behalf of the CUHK-PWH Diabetes Care and Research Team

2 General outline Burden of diabetes and chronic diseases Multicausality and complexity of diabetes From diabetes registry to risk stratification Compliance and treatment gaps From clinical trials to collaborative care From research to practice to policy From disease control to prevention

3 6 asset price collapse 4 China slowing economy to 6% 31 chronic disease

4 Asia epicentre of diabetes 110 million affected 2 million deaths Per year

5 1 in 4 people in China has diabetes or pre-diabetes 88% Yang WY et al NEJM 2010

6 Burden of diabetes in Hong Kong Estimated 700,000 people with diabetes 50% undiagnosed 70% diagnosed in public setting 20,000 new cases per year 34.7% - CVD 27.2% - stroke 38.0% - dialysis 200,000 hospitalizations 17% of all admissions 1.2 million hospitalization days 1 million specialist clinic visits Number of patients in HA 300, , , , ,000 50, Year Standard Report on DM Workload Statistics CDARS Courtesy of Dr WY So

7 Diabetic complications are expensive and difficult to treat % of health care costs spent on diabetes 80% used to treat late complications fold increase of cost micro macro micro+macro CHD renal Chen X et al Chinese Diabetes J 2003

8 Complexity of diabetes: multiple causes, processes & consequences Age Lifestyle Environments Nutrition Smoking Psychosocial stress Chronic infections Intrauterine environment Dysregulation of energy balance, cell cycle, neurohormonal and inflammatory responses Beta cell Insufficiency Gene Intergenic region Epigenome Gene Hyperglycemia Insulin resistance Blood pressure Dyslipidemia Exogenous factors Gene obesity Inflammation Stroke Kidney disease Heart disease Depression Cancer Mortality and morbidity

9 Every person with diabetes is unique

10 Reducing the burden of chronic diseases Where is the bottleneck? Large patient population with or at risk of chronic diseases Lack of awareness and periodic assessments Lack of symptoms Frequent default Organ damage, expensive care Large clinic size Short contact time Non compliance Advanced presentation Suboptimal risk factor control

11 Using a trio-team to set up the PWH-CUHK Diabetes Registry since 1995

13 Diabetes and co-morbidities Hong Kong Diabetes Registry >10,000 patients since % Type 1 diabetes 96.3% Type 2 diabetes Mean age: 57.4 years Mean disease duration: 5 years Mean follow up period: 6 years cancer stroke heart failure CHD 38% A major event ESRD Death %

14 Diabetes and cancer Hong Kong Diabetes Registry Causes of death In 7000 T2D FU 6 years 1% A1c 18% cancer risk So WY et al DMRR 2008 Yang XL et al Diabetes 2010

15 Diabetes, vascular-, cancer-, non-vascular and non-cancer deaths Seshasai, SR et al NEJM 2011

16 Fasting plasma glucose and deaths Seshasai, SR et al NEJM 2011

17 Low BMI and high waist predict diabetic kidney disease Luk A et al Diabetes Care 2008

18 Interactive effects of albuminuria and retinopathy on new event rate in 3.5 years % with events in 3.5 years no Cx Ret Micro Macro Ret+Micro Ret+Macro CVS renal death composite Tong PCY et al Diab Med 2007

19 High white blood and smoking predict micro/macrovascular diseases Low red cell count predicts major clinical events Tong PCY et al Diabetes Care 2004 Tong PCY et al Diabetes Care 2009 Erectile dysfunction predicts heart disease Chronic HBV infection predicts ESRD HBV+ve HBV-ve Ma RCW et al JACC 2009 Cheng A et al Diabetologia 2006

20 Both egfr and ACR predict CVD in T2 DM (4421 Chinese T2D patients 3 year FU) egfr<60 (5-10% per year) egfr 60 (2-5% per year) So WY et al Diabetes Care 2006

21 Hong Kong Diabetes Risk Equation for all cause death Mortality risk score (ROC=0.85) Predictors age Female BMI-26.0 High ACR Low egfr Low Hb Peripheral vascular disease history of cancer use of insulin Yang XL et al Arch Int Med 2008

22 Joint Asia Diabetes Evaluation (JADE) Program from concept to implementation Risk Stratification Evidence based clinical protocols Data collection Prompts and recommendations Feedback (charts, trends) Quality assurance Benchmarking Ongoing analysis Quality improvement

Joint Asia Diabetes Evaluation (JADE) Program from evidence to practice Information technology Efficacy Effectiveness Protocol Multidisciplinary

23 Joint Asia Diabetes Evaluation (JADE) Program from evidence to practice Information technology Efficacy Effectiveness Protocol Multidisciplinary care Evidence Communication Policymakers Payers Public Patients Providers Best medical practice Cost effective use of resources Improved quality of life

24 Using information technology to augment quality of diabetes care

25 Protocols and risk engine Ko G et al BMC Med Info Decision Making, 2010

26 Decision support and empowerment Ko G et al BMC Med Info Decision Making, 2010

Risk stratification and clinical outcomes 5 year

complications 3: CKD or at least 3 risk factors or

medium risk score 1: no CKD and 1 or no risk

27 Risk stratification and clinical outcomes 5 year event rates 38% 18% 8% Risk levels 4: Cardio-renal complications 3: CKD or at least 3 risk factors or high risk score 2: no CKD and 2 risk factors or medium risk score 1: no CKD and 1 or no risk factor and low risk score 5% Chan JC et al Diabetic Med 2009

28 Complications and risk factors in Asian T2D patients 100% 80% 60% Level 4 Level 3 Level 2 40% Level 1 20% 0% Total, n=3687 HK, n=832 IN, n=788 KR, n=295 PH, n=1186 SG, n=256 TW, n=55 TH, n=275 So WY et al J of Diabetes 2011

30 ABC targets in Asian T2D patients Total (3687) HK (832) India (788) Korea (295) Ph (1186) Sing (256) HbA 1c <7% TW (55) Thai (275) BP<130/80 mmhg LDL-C<2.6 mmol/l No target achieved Any 1 target achieved Any 2 targets achieved All 3 targets achieved So WY et al for JADE Study Group J of Diabetes 2011

31 50% rule From awareness to action to outcomes 12% 6% 3%! 25% 50% 100 subjects 50% of whom are aware of need to take action 50% of whom decide to take action 50% of whom have ability to take action 50% of whom will actually take action 50% of whom will achieve outcome

32 Clinical inertia by care providers A1c>8% Miccoli R et al Diabetes Care 2011 Adapted from Shah BR et al Diabetes Care 2005

33 50% of patients on 5 or more chronic medications are not compliant 60% of patients on CVS drugs 40% of patients on anti-diabetic drugs Wu J et al BMJ 2006

34 From clinical trials to disease management BMJ 1992:305: Kidney International 2000;57: Am J Manag Care 2004;9:

35 Clinical trials = Protocol + team + monitoring = Clinical benefits Death rate 70% All events 50% So WY et al Am J Managed Care 2003

36 Clinical trials versus clinical practice Newly Diagnosed 50 yr old Microalb 55 yr old 30% CHD 60 yr old Chan JCN. J Diabetes Investigation 2011

37 Managing high risk diabetic patients

38 Team + protocol + monitoring = saves life and money % of patients reaching 3 targets usual structured N=104 N=101 Targets A1c<7% BP<130/80 mmhg LDL-C<2.6 mmol/l TG<1.7 mmol/l RAS blockers 60% Risk reduction Chan JCN et al Diabetes Care 2009

39 Collaborative care between hospital and community care teams no. of admisssion/100 patient Non participants Participants time(days) WY So, Chan JCN, H Fung, Chu E et al, 2000

40 Living with diabetes Diet Body weight Exercise Medications (DM or non-dm) Emotions Other Illnesses

42 Protocol, collaborative care and peer support Primary care Patients and carers Collaborative Care Peer Support Hospital team Nurses & paramedics

43 Diabetes, depression and CHD

44 Impacts of collaborative care on risk factor control month 12 month ABC targets A1c>1% BP>10mmHg Global improvement Risk factor control at 12 months Katon A et al NEJM 2011

45 Translating evidence to practice

46 From research to practice to policy 2009

47 Hong Kong Reference Framework for Diabetes Care in Primary Care Settings Convened by Prof S Griffiths

HA Risk Stratification and Chronic Care Model

Primary care SCP RAMP Medium risk Primary care

clinics Specialist Empowerment, Intensive

48 HA Risk Stratification and Chronic Care Model Risk assessment & Stratification Low risk Primary care SCP RAMP Medium risk Primary care SCP PEP DM patients High risk Nurse clinics Internist Nurse led clinic with Multidisciplinary team Very High risk Nurse clinics Specialist Empowerment, Intensive Treatment, Treat-to-target, SCP=shared Care Program evidence & protocol based care PEP=Patient Empowerment Program RAMP=Risk Assessment and Management Program Courtesy of Dr Linda Yu

49 Prevention and control of diabetes A multisectoral, multidisciplinary & multidimensional challenge

50 Promoting health starting from school

51 Tobacco control campaign Recognition by WHO

52 Healthy eating Nutrition labeling, sodium intake, Eat Smart Program

53 Maximizing synergism and minimizing gaps Together Everybody Achieves More Paramedics Patients Specialists Industry Primary care Academia Community Policymakers Raising awareness Capacity building System strengthening Mandates, Incentives, audits

54 Thank you! CUHK-PWH Diabetes Care and Research Team Special acknowledgement to Prof Clive Cockram, Drs. Fung Hong, CC Chow, WY So, Peter Tong, Gary Ko, Linda Yu, Ms Rebecca Wong and her team

Integrating Medical and Social Support for Elderly System & Technology Enabled Service Innovations. Dr Christina MAW Hospital Authority, Hong Kong

Integrating Medical and Social Support for Elderly System & Technology Enabled Service Innovations Dr Christina MAW Hospital Authority, Hong Kong Hospital Authority (HA) of Hong Kong A statutory body responsible