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

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

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

We Must Have A Centre !

A Multi-disciplinary Diabetes Centre

Family Doctor

Dietitian

Diabetes Nurse/ Educator

Podiatrist

Specialist

Secretaries

ResearcherPerson with Diabetes

What We Need Is Not A Diabetes Education Centre

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

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

Visit 1

Visit 2

Visit 3

Visit 4

Patient 1 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 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

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

•Medical Data

E-mail

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.

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

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

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

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

A Transplant of Diabetes Centre to Rural Area

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

Training and Exchange ProgramsNational and International

Clinical Research and Basic Science Research

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

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

D.

mI Cho

Cr/PCr

Gluc

Glx/GABA

B.

C.NAA

Sorensen L et al : Diabetes Care 2008 ; 31(5) : 980-1

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

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

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

Nurse Dietitian

DoctorDoctor Nurse

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 CareRoyal 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