One year outcomes of Type 2 Diabetes Mellitus Patients after an Integrated Patient Care Plan (IPCP) Presented by APN Ng Sau Yee NTW Diabetes Centre

Transcription

1 One year outcomes of Type 2 Diabetes Mellitus Patients after an Integrated Patient Care Plan (IPCP) Presented by APN Ng Sau Yee NTW Diabetes Centre

2 Background No endocrine team in NTWC before 2003 Great practice variation in diabetes care between doctors and between settings Care provision are largely disorganized and fragmented

3 Background Use of care pathway (Integrated Patient Care Plan - IPCP) w.e.f 2004 to: integrate hospital & primary health care in the care of diabetic patients provide patient education and empower them in self-management enhance family medicine physician s training with specialized knowledge & skills

4 What is IPCP? A comprehensive model using structured multidisciplinary critical pathway, commencing at the point of presentation of illness, from acute phase to rehabilitation phase and extended to community setting. Every indispensable intervention across all these levels of care is systematically planned, coordinated, implemented, monitored & evaluated, so as to ensure the health care needs of the clients are met.

5 How IPCP can be adopted to Diabetes Care? Practice supported by evidence Collaboration between endocrinologist, FM physician, diabetes nurse & dietitian Involvement of patients and family needs Consistent and structured care delivered Standard patient information provided

6 Subjects Inclusion Criteria Newly referred non insulin-requiring Type 2 DM Never received formal diabetic education Exclusion Criteria Significant mental or physical disability Limited life expectancy/ poor quality of life Co-existing disease requiring other specialist care

7 Referred cases IPCP Flow Diagram Triage in SOPD 1st Visit: Assessment Preliminary Ix & Arrange Complication Screening Start education program Start or titrate medical Rx Arrange to see dietitian Refer MSW, podiatrist PRN POH FM-DM clinic 2nd visit: Continue education Review Ix results Intensify medical treatment 3rd visit: Continue and evaluate education Further drug titration Discharge patients according to disease status Ward SOPD GOPC Hospital Community

8 Objectives of current study This is a retrospective study To examine patients changes in Metabolic control Persistence in self monitoring of blood glucose (SMBG) in 3 points of time upon entering IPCP on discharge from IPCP 1 year after completion of IPCP

9 Methods Patients biochemical data (from Feb 19, 2004 Dec 31, 2006), including BW, BMI, BP, HbA1c level, lipid profile and persistence of SMBG, were retrieved from CMS or phone enquiry Significance of change in biochemical data were analyzed by Paired t-tests SMBG persistence was analyzed by Chi square test

10 Results No. of patients recruited into IPCP: 505 No. of patients completed IPCP over 1 year: 235 Subjects demographic data (n=235) Sex Age Male 126 (53.6%) Female 109 (46.4%) Range Mean (S.D.) (11.65)

11 Referral Sources 8.1 % 41.3 % 21.7 % GOPC GP POH TRIAGE CLINIC AED OTHER SPECIALTY 6 % OTHERS (e.g. POH 24 hr clinic, Staff clinic) 5.5 % 17.4 %

12 Metabolic Control for patients FU GOPC on discharge (n=188) Baseline Data On discharge from IPCP 1 year after discharged from IPCP Data p-value* Data p-value* BW (Kg) 67.3 ± ± ± BMI (Kg/m 2 ) 25.9 ± ± ± SBP (mmhg) 134 ± ± ± DBP (mmhg) 76 ± ± ± HbA1c (%) 8.35 ± ± ± *Paired t-test, results vs. baseline data

13 Metabolic Control for patients FU GOPC on discharge (n=188) Baseline Data On discharge from IPCP 1 year after discharged from IPCP Data p-value* Data p-value* TC (mmol/l) 5.31 ± ± ± LDL (mmol/l) 3.18 ± ± ± HDL (mmol/l) 1.29 ± ± ± TG (mmol/l) 1.95 ± ± ± *Paired t-test, results vs. baseline data

14 Self-Blood Glucose Monitoring for patients FU GOPCs on Discharge (n=188) (%) 50 * 40.8 % * % % 10 0 Before IPCP On discharge from IPCP 1 year discharged from IPCP * vs. baseline, Chi square test, p<0.0001

15 FU Location On discharge of IPCP (%) % (after 1 year) GOPC % (after 1 year) 6.4 % (after 1 year) MED SOPD DEFAULT FU OTHERS GOPC MED SOPD DEFAULT FU OTHERS

16 Conclusions IPCP: Effective & sustainable model in triaging, empowering self-management & maximizing initial medical treatment of newly referred Type 2 DM patients. FU GOPCs cases: Significant improvement on discharge from IPCP: BW, BMI, DBP, HbA1c, TC and LDL Significant improvement both on discharge and 1 year after IPCP: HbA1c and DBP

17 Recommendations 1) Incorporate exercise programme through collaboration with physiotherapist 2) Regular reinforcement of self-management at GOPC or medical clinic to maintain metabolic control

18 Team Composition Team Leader Dr. Andrew Ho, AC (M&G), TMH Subject Officer Betty Au, CGM(N), NTWC Subject Coordinator Vivian Chan, DOM, NSD, POH Subject Facilitator Tang Pui Fun, APN, NSD, NTWC Team Members Dr. Jun Liang, CON (FMed), TMH Dr. Dorothy To, SMO (FMed), TMH Dr. Laam Chan, MO (FMed), TMH Agatha Chan, Diabetes NS, POH Ng Sau Yee, APN, M&G, POH Chow Miu Fan, DM nurse, POH Mrs Sally Ng, CC (Diet), NTWC Joanne Koo, Dietitian, POH Ma Ka Man, Triage Nurse, ACC,TMH

19