Dennis Yue Director of Diabetes, Royal Prince Alfred Hospital
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The Multi-disciplinary Diabetes Centre : A Model of Care for the Future (or the Past) ?
Dennis YueDirector of Diabetes, Royal Prince Alfred Hospital
Kellion Professor of Endocrinology, University of Sydney
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Conference in China
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The Burden and Complexity of Diabetes
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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
Target Achieved (%)
Cholesterol < 4mmol/L 24 24 27
BP 26 35 28
HbA1c within 1% of normal range
29 44 41
ANDIAB Survey : Cheung NW et al : Diabet Med 2008 ; 25(8) : 974-8
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We Must Have A Centre !
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A Multi-disciplinary Diabetes Centre
Family Doctor
Dietitian
Diabetes Nurse/ Educator
Podiatrist
Specialist
Secretaries
ResearcherPerson with Diabetes
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What We Need Is Not A Diabetes Education Centre
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Referring Doctor
Complications and Metabolic Management
(Type 1 & 2)
Review ClinicFollow-Up Clinic
High Risk Foot Clinic
Acute InterventionClinic
PregnancyClinic
Referring Doctor
Waiting time 0 to 2 weeks
Waiting time 6 months
Within 4 months
A Multi-disciplinary Diabetes Centre(Education is Integrated with Clinical Service and Care is Shared)
Hoskins PL : Diab Med 1993; 10(1) : 81-6Overland J et al : Diabetes Res Clin Pract 1999 ; 44(2) : 123-8Constantino M et al : Med J Aust 1991 ; 155(8) : 515-8
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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
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Standardised Data Capture
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Younger Onset of Type 2 Diabetes Increases Risk of Retinopathy
Wong J et al : Diabetes Care 2008; 10 : 1985-90
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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
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Ambulatory Stabilisation of Diabetes : Commencing Insulin Therapy
Hoskins PL et al : Med J Aust 1993 ; 158(3) : 148-9
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Telephone Stabilisation
Genev NM et al Diabet Med 1990 ; (1) : 920-1
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Changing Pattern of Treatment of Type 1 Diabetes :More Use of Carbohydrate Counting and Insulin Pump
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Continuity of Care in a Multi-disciplinary Setting
Visit 1
Visit 2
Visit 3
Visit 4
Patient 1 Patient 2
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Standardised Format of Letters(Documentation and Education)
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Infrastructure Support
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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
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The High Risk Diabetic Foot ClinicA 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
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Benefits of Multi-disciplinary Foot Clinics (RPAH): Prevalence and Level of Amputation
Distal Below Knee Above Knee0
10
20
30
40
50
60
70
80
90
Clinic
No Clinic
Per
cen
tag
e o
f A
mp
uta
tio
ns
(%) 2 =14.6; P=0.001
McGill M et al : Intern Med J 2005 ; 35(8) : 451-6
Nube VL et al : The Diabetic Foot Journal 2008 ; 11, 187-193
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•Medical Data
High Risk Foot Clinics
DubboLismoreNowraOrange
GraftonPort Macquarie
GriffithForbesQuirindi
Mullumbimby
How Does Telemedicine Work?
McGill M & Constantino M et al : Practical Diabetes 2000 ; 17(7) : 235-238.
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Clinical Trials
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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
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The Power of Computer
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The Under Water Volcano Theory of GDM
Ross GP et al Diabet Med ; 13(8) : 748-52
Ethnic Susceptibility to GDM is a Function of Ethnic Difference in Age of Onset of Type 2 Diabetes
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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
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Metabolic Syndrome in Type 1 Diabetes
McGill M et al : J Diabetes Complications 2008 ; 22(1) : 18-23
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Molyneaux L et al : Diabetes Obesity and Metabolism 2004 ; 6 : 187-94
Strong Family History Predicts A Younger Age Of Onset For Subjects Diagnosed With Type 2 Diabetes
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A Transplant of Diabetes Centre to Rural Area
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Overseas CollaborationsFiji and Kirabati China
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
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
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Training and Exchange ProgramsNational and International
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Clinical Research and Basic Science Research
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Brooks B et al : Diabetes Care 1999 ; 22(10) : 1722-7
Brooks B et al : Diabet Med 2001 : 18(5) : 374-80
Biomedical Research on Diabetic Complications
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
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Skin Biopsy to Assess Small Fibre Diabetic Neuropathy
Sorensen L et al : Diabetes Care 2006 ; 22(3) : 261-5
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Magnetic Resonance Spectroscopy in the Study of Diabetic Neuropathic Pain
D.
mI Cho
Cr/PCr
Gluc
Glx/GABA
B.
C.NAA
Sorensen L et al : Diabetes Care 2008 ; 31(5) : 980-1
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Relationship Between Age of Diabetes Onset and Mitochondrial DNA Content
r=0.7:p=0.0002
r=-0.04:p=0.8
No comps
Comps
Wong J et al Diabetologia 2009 ; 52(9) : 1953-61
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Wound Fluid MMP-9 and TIMP-1 Levels Predict Poor Wound Healing
Liu Y:- Diabetes Care 2009 ; 32(1) : 117-9
0
2
4
6
8
10
MMP-9
MM
P-9
(μ
g/m
l)
*
*
Ratio of MMP-9/TIMP-1
MM
P-9
/TIM
P-1
(x1
00)
0
5
10
15
20
25
**
*
* p<0.05, ** p<0.01 different from healed within 12 weeks
pro-MMP-9 act-MMP-9
HealedUnhealed
HealedUnhealed
pro-MMP-9/TIMP-1 act-MMP-9/TIMP-1
Xu, L et al Diabetes Care 2007;30(2):378-80
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The Relationship of Monocyte Surface Markers with Diabetes and Retinopathy
Min D et al : American Diabetes Association Meeting 2010
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Research in a Multi-disciplinary Setting :Less linear than thematic
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The Interactive Multi-disciplinaryTeam
Nurse Dietitian
DoctorDoctor Nurse
Dietitian
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What is an Interactive Team ?
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Weekly Training Sessions
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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
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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 !!!
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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
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The Diabetes Centre Model of CareRoyal Prince Alfred Hospital
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The Italian Way
If you never never go, you will never never know
Rome was burnt in one day in AD 64
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A Model in Danger of Evolutionary Extinction
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Number Of Patient Services Per Year
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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.
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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 ?
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Organization of the Diabetes Movement
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Thanks for the Family !
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A Chance Meeting